Medicare Outpatient Prospective Payment System Proposed Rule Released

Posted on August 02, 2019

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) effective Jan. 1, 2020. Key highlights of the proposed rule include:

  • Requiring hospitals to publicly disclose payer-specific negotiated rates and gross charges for at least 300 shoppable services (nonurgent healthcare services that can be scheduled in advance), including 70 CMS-selected services and a minimum of 230 hospital-selected shoppable services.
  • Continuing the phase-in of the site-neutral payment rates that will pay 40% of the OPPS rate for clinic visits provided in grandfathered off-campus hospital outpatient departments, down from the current 70% of the OPPS rate.
  • Continuing the nearly 28% payment cut implemented in 2018 for drugs purchased under the 340B drug savings program.
  • Changing the minimum required level of supervision from direct to general supervision for all hospital outpatient therapeutic services provided by all hospitals, including critical access hospitals.
  • Increasing OPPS payment rates by a net 2.4% after budget neutrality and all adjustments.
  • Increasing the outlier cost threshold by 2.6% from the current $4,825 to $4,950.
  • Revising the area wage index to incorporate changes that are adopted in the hospital inpatient prospective payment system (IPPS) final rule, which is expected to be released soon. In the FY 2020 IPPS proposed rule, the CMS advised maintaining budget neutrality by funding an increased wage index value for hospitals in the bottom quartile through a decrease for hospitals with values in the top quartile. The IPPS proposed rule also included a proposal that the FY 2020 wage index for each hospital be at least 95% of its final FY 2019 wage index.
  • Establishing a prior authorization process for five categories of hospital outpatient department services that can be considered cosmetic procedures including: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation.
  • Removing total hip arthroscopy from the inpatient-only list, making it payable by Medicare in the hospital outpatient setting.

Within the next few weeks, the MHA will provide members with hospital-specific estimates of the proposed rule’s impact. In addition, the MHA will make its draft comments available prior to the Sept. 27 due date and encourages hospitals to submit comments to the CMS. The CMS is expected to release a final rule by Nov. 1 for the Jan. 1, 2020, effective date. Members with questions should contact Vickie Kunz at the MHA.

Tags: Medicare, OPPS, 340B Drug Pricing Program, proposed rule, wage index, price transparency

Posted in: Member News

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