Medicare Payment Rule Finalized for Outpatient and Ambulatory Services in 2019

Posted on November 05, 2018

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

  • Increasing OPPS payment rates by a net 1.1 percent, from $78.64 to $79.49, for hospitals that comply with outpatient quality reporting program (QRP) requirements. The net increase is the result of the 2.9 percent marketbasket adjustment reduced by a 0.8 percentage point for productivity, a 0.75 percentage point that is required by law, and budget neutrality.
  • Reducing payment for clinic visits provided at “grandfathered” off-campus hospital outpatient departments (HOPDs) to 70 percent of the OPPS rate in 2019 and 40 percent in 2020. 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.
  • Reducing payments for 340B drugs provided in nongrandfathered HOPDs to the average sales price (ASP) minus 22.5 percent payment rate. In addition, the CMS will 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. 
  • Reducing payment for new drugs and biological products before ASP data is available. The final rule provides payment at wholesale acquisition cost (WAC) plus 3 percent, down from WAC plus 6 percent. 
  • Removing eight measures from the outpatient QRP, with one measure removed beginning with the 2020 payment determinations and the other seven with the 2021 payment determinations.  
  • Modifying the Hospital Consumer Assessment of Healthcare Providers and Systems patient experience-of-care survey measure for inpatient services by removing the three recently revised pain communication questions, starting with Jan. 1, 2022, discharges. 
  • Expanding the covered procedures list for procedures covered by Medicare when provided in an ASC by adding 12 cardiovascular codes and five additional codes to the ASC.

In the next few weeks, the MHA will provide additional information on the OPPS final rule, including hospital-specific impact analyses. Members with questions should contact Vickie Kunz at the MHA.

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

Posted in: Member News

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