Month / Year
Subject

Category: Transmittals

OPPS Proposed Rule – CY 2019

CMS-1695-P drafted on 7/25/2018; Published in the Federal Register on 7/31/2018

On July 25, 2018, the Centers for Medicare & Medicaid Services (CMS) proposed changes to ensure that seniors can access the care they need at the site of care that they choose and to lower drug prices as outlined in the President’s Blueprint. The proposed policies in the CY 2019 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule would help lay the foundation for a patient-driven healthcare system.

To increase the sustainability of the Medicare program and improve quality of care for seniors, CMS is moving toward site neutral payments for clinic visits (which are essentially check-ups with a clinician). Clinic visits are the most common service billed under the OPPS. Currently, CMS often pays more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.  If finalized, this proposal is projected to save patients about $150 million in lower copayments for clinic visits provided at an off-campus hospital outpatient department. CMS is also proposing to close a potential loophole through which providers are billing patients more for visits in hospital outpatient departments when they create new service lines.

As part of active efforts to reduce the cost of prescription drugs, CMS is issuing a Request for Information to solicit public comment on how best to leverage the authority provided under the Competitive Acquisition Program (CAP) to get a better deal for beneficiaries as part of a CMS Innovation Center model. CMS believes a CAP-based model would allow the program to introduce competition to Medicare Part B, the part of Medicare that pays for medicines that patients receive in a doctor’s office.

In 2018, CMS implemented a payment policy to help beneficiaries save on coinsurance on drugs that were administered at hospital outpatient departments and that were acquired through the 340B program-a program that allows hospitals to buy certain outpatient drugs at a lower cost. Due to CMS’s policy change, Medicare beneficiaries are now benefiting from the discounts that 340B hospitals enjoy when they receive 340B-acquired drugs. In 2018 alone, beneficiaries have saved an estimated $320 million on out-of-pocket payments for these drugs. For 2019, CMS is expanding this policy by proposing to extend the 340B payment change to non-excepted off-campus departments of hospitals that are paid under the Physician Fee Schedule.

CMS is also seeking comment through a Request for Information asking whether providers and suppliers can and should be required to inform patients about charge and payment information for healthcare services and out-of-pocket costs, what data elements would be most useful to promote price shopping, and what other changes are needed to empower healthcare consumers.

Overall, the proposed rule is projected to result in an estimated decrease of $610M (or -0.1%) in payments to providers, ranging from 3.4% decreases for hospitals in the New England region up to 2.1% increases for non-teaching, non-DSH urban hospitals.

For more information regarding this Proposed Rule, see below:

Fact Sheet Link

Federal Register Link

Medicare OPPS Base Rates

CMS is proposing a base rate increase of 1.25% for hospitals that submit OQR quality data and 2.0% for ASCs that submit ASCQR quality data.

APC Changes

As expected, CMS is proposing weighting changes to APC weights for CY2019, along with new APC codes and new HCPCS codes. Below is a listing of the largest changes in weighting between CY2018 and CY2019 APCs:
 
Click here for a table of the full APC weighting comparison between CY2018 and CY2019.
 
Click here for a table of the new HCPCS codes effective 7/1/2018.
Other APC Changes
CMS has proposed to create three new comprehensive APCs (C-APCs) for ears, nose, and throat (ENT) and vascular procedures. CMS also proposes to remove two procedures from the inpatient-only list and add one procedure to the list.
Click here for a table of the changes to the inpatient-only procedures.

Changes to Quality Reporting

CMS is proposing several changes to the Outpatient Quality Reporting (OQR) in an effort to reduce burdens on hospitals, including the removal of 10 measures from the OQR (1 from CY2020 and 9 from CY2021). CMS also proposes to remove the three recently revised pain communication questions, starting with services on Jan. 1, 2022, to address concerns that providers might feel pressure to offer opioids in order to raise survey scores.
Click here for a table of the 10 OQR measures proposed to be removed.
 
Click here for a table of the 26 OQR measures required for CY 2020 and here for a table of the 15 ASCQR measures required for CY2020.

Off-Campus Payment Policy Changes

CMS remains concerned with the shift of services from freestanding physician offices to hospital provider-based departments (PBDs). As a result, they are proposing several significant changes that will negatively impact OPPS reimbursement for these facilities:
Expansion of PFS Rate for All Clinic Visits: CMS will extend the reduced Physician Fee Schedule (PFS) rate for clinic visits (HCPCS code G0463) to all off-campus PBDs, even those excepted under Section 603. (Note: The PFS payment rate is approximately 40% less than the OPPS rate.)CMS estimates that the impact of this change is expected to reduce reimbursement to hospitals by $760M.
Restricting “Clinical Families of Services”: CMS is also proposing to require that if an excepted off-campus PBD furnishes services from any clinical family of services from which it did not furnish and bill during the period from 11/1/2014 to 11/1/2015, such items and services would be paid at the reduced PFS rate applied to non-excepted off-campus PBDs. New items or services within a clinical family of service would continue to be paid under OPPS, as this would be considered a “service expansion.” For mid-build providers, CMS proposes a 1-year baseline period beginning on the first date the off-campus PBD furnished the service under OPPS.
Click here for a table of the clinical families of services.
New “ER” Modifier: Finally, CMS also plans to require a new “ER” modifier to identify services in off-campus ER departments. This is meant to address the MedPAC recommendation for CMS to assess the extent to which OPPS services are shifting to off-campus ER departments. (Critical access hospitals would be exempt from this reporting requirement.)

Changes to Drug Payment Policy 

In response to the President’s Commission on Combating Drug Addiction and the Opioid Crisis, CMS proposes to change the packaging policy for certain drugs. CMS is also proposing to change the payment for separately payable drugs for non-excepted off-campus PBDs to the same lower ASP minus 22.5% (or 77.5% of ASP) that excepted off-campus PBDs receive. Currently these non-excepted departments receive 106% of ASP for these drugs. SCHs, Children’s, and Cancer hospitals would be exempt.
 
Click here for a table of the drugs and biologicals with pass-through status expiring on 12/31/2018.

CMS Request for Information

CMS is seeking feedback as to how providers may safely and effectively transition EHR among other providers and thereby improve interoperability.

CMS is also interested in continuing the discussion as to how hospitals might improve access to charge information across providers in order to help patients understand their financial liability, including out-of-pocket costs.

Finally, CMS is soliciting comments on key designs for developing a potential model that would test private market strategies and introduce competition to improve quality of care for beneficiaries, while reducing both Medicare expenditures and beneficiaries’ out-of-pocket spending.  They are seeking feedback that would accelerate the move to a value-based healthcare system building upon the Competitive Acquisition Program (CAP) for Part B drugs.

For additional information, please contact Ron Knapp at ron.knapp@toyonassociates.com.

Other Recently Published Proposed Rules  

CY 2019 HHA PPS Proposed Rule [CMS-1689-P]
(FR Publish Date 7/12/2018)
  • Expected 2.1% increase in payments to HHAs in CY 2019
  • Rural add-on payment extended for CYs 2019 through 2022 with new methodology
  • Cost of remote patient monitoring will be allowable costs on the Medicare cost report
CY 2019 ESRD PPS and DMEPOS Proposed Rule [CMS-1691-P]
[FR Publish Date 7/19/2018)
  • Proposed ESRD
  • Updates to ESRD QIP measures and codifying several previously finalized requirements
  • Changes to the DMEPOS Competitive Bidding Program (CBP)
Physician Fee Schedule, Quality Programs, and Medicaid Interoperability Proposed Rule [CMS-1693-P]
(FR Publish Date 7/27/2018)
  • Updates to PFS RVUs, including an increase in the conversion factor of 0.13% to $36.0463
  • Elimination of payment distinction and documentation requirements E&M visit levels 2
    through 5
  • 50% multiple procedure payment adjustment when E&M visits and procedures with global periods are furnished together
  • Moving forward with Appropriate Use Criteria (AUC) using a Clinical Decision Support Mechanism (CDSM)
    >Effective 1/1/2020, physicians and other practitioners who order advance diagnostic
    imaging must consult with AUC and report the consultation information on the claims.
Back to top

Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMB) for Medicare Cost-Sharing

From: CMS Transmittal 1747 (Pub 100-20) – 11/4/16

SUMMARY OF CHANGES: The purpose of this Change Request is to instruct Medicare Administrative Contractors (MACs) to accept Beneficiary Contact Center (BCC) referrals of beneficiary inquiries involving Qualified Medicare Beneficiary (QMB) billing problems, issue Compliance letters to named providers and send a copy of the provider Compliance letter to the named beneficiary with an explanatory cover letter.

Federal law bars Medicare providers from charging Qualified Medicare Beneficiary Program (QMB) individuals for Medicare Part A and B deductibles, coinsurances, or copays. Medicare providers must accept the Medicare payment and Medicaid payment (if any) as payment in full for services rendered to a QMB individual. Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. Sections 1902(n)(3)(C); 1905(p)(3); 1866(a)(1)(A); 1848(g)(3)(A) of the Social Security Act.

Effective, September 19, 2016, Beneficiary Contact Center (BCC) Customer Service Representatives (CSRs) will implement protocols to identify a caller’s QMB status and advise them about QMB billing protections. Within 30 days of implementing this Emergency CR, BCC CSRs will escalate certain beneficiary inquiries involving improper QMB billing to the appropriate MAC through the Next Generation Desktop (NGD) in accordance with the Complex Inquiry Escalation National Operating Procedures. MACs are instructed by CMS to issue a compliance letter within applicable complex inquiry timeframes (within 25 business days for at least 75 percent and within 45 business days for 100 percent of all inquiries referred) instructing named providers and suppliers to refund any erroneous charges and recall any past or existing billing

Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMB) for Medicare Cost-Sharing

Back to top
Back to top

Here TO HELP

Receive a no obligation consultation on how Toyon can help make your cost reporting simpler, easier, and trusted.