Medicare Payment Rule Proposed for Outpatient and Ambulatory Services in 2019

Posted on July 26, 2018

The Centers for Medicare & Medicaid Services (CMS) recently released the proposed rule to update the Medicare fee-for-service (FFS) outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment systems effective Jan. 1, 2019. Highlights of the proposal include:

  • A net 1.25 percent increase in OPPS payment rates, after the 2.8 percent marketbasket adjustment is reduced by the 0.8 percentage point adjustment for productivity and 0.75 percentage point adjustment required by law. For hospitals that comply with outpatient quality reporting program (QRP) requirements, after budget-neutrality adjustments, the CMS proposes a conversion factor of $79.55 for 2019, up 1.2 percent from the 2018 rate.
  • A reduction in the payment rate for clinic visits provided at all off-campus hospital outpatient departments (HOPDs) to 40 percent of the OPPS rate. Currently, clinic visits at off-campus HOPDs that were “grandfathered” under Section 603 of the Bipartisan Budget Act of 2015 are paid at 100 percent of the OPPS rate, while clinic visits at nongrandfathered off-campus HOPDs are paid at 40 percent of the OPPS rate. This proposal would greatly reduce payment to the grandfathered facilities for those services. In addition, the CMS proposes to pay for services in new clinical families provided at off-campus HOPDs under the physician fee schedule (PFS) rather than the OPPS.  
  • Changes to the 340B and other drug payment policies. Under the proposal, the average sales price (ASP) minus 22.5 percent payment rate for drugs acquired under the 340B program would be extended to 340B drugs provided in nongrandfathered HOPDs. The CMS also proposes to pay for separately payable biosimilars acquired under the 340B program at ASP minus 22.5 percent of the biosimilar’s own ASP, rather than at ASP minus 22.5 percent of the reference product’s ASP.  
  • A reduction in payment for new drugs and biological products before ASP data is available. The proposed payment is wholesale acquisition cost (WAC) plus 3 percent, down from WAC plus 6 percent.  
  • Similar to the CMS’s Request for Information (RFI) included in the inpatient PPS and the recent PFS proposed rule, the OPPS proposed rule includes an RFI asking whether providers and suppliers can and should be required to inform patients about charges and payment information for services and out-of-pocket costs, what data elements the public would find useful, and what other changes are needed to empower patients.  
  • The removal of 10 measures from the outpatient QRP, including one measure to be removed for 2020 and nine measures removed beginning with 2021. In addition, the CMS proposes to modify the Hospital Consumer Assessment of Healthcare Providers and Systems patient experience-of-care survey measure by removing the three recently revised pain communication questions, starting with Jan. 1, 2022, discharges.  
  • The addition of procedures that Medicare would cover when provided in an ASC. Under current policy, covered surgical procedures may include those with certain Common Procedural Terminology (CPT) codes that are within the surgical code range or other types of codes that directly crosswalk or are clinically similar to CPT codes within the surgical code range. For 2019, the CMS proposes to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the covered procedures list, specifically adding certain cardiovascular codes for coverage in ASCs. In addition, the CMS proposes to review all procedures added within the past three years to reassess recent experience and determine whether these procedures should continue to be covered in the ASC setting.  

In the next few weeks, the MHA will provide additional information on the OPPS proposed rule, including hospital-specific impact analyses. The association also will make its draft comments available prior to the due date and encourages hospitals to submit comments to the CMS by Sept. 24. A final rule is expected by Nov. 1 for the Jan. 1, 2019, effective date. Members with questions should contact Vickie Kunz at the MHA.

Tags: OPPS, 340B Drug Pricing Program, proposed rule, CMS, ASC

Posted in: Member News

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