OPPS Proposed Rule – CY 2019
CMS-1695-P drafted on 7/25/2018; Published in the Federal Register on 7/31/2018
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:
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.
Changes to Quality Reporting
Off-Campus Payment Policy Changes
Changes to Drug Payment Policy
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 firstname.lastname@example.org.
Other Recently Published Proposed Rules
- 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
- Proposed ESRD
- Updates to ESRD QIP measures and codifying several previously finalized requirements
- Changes to the DMEPOS Competitive Bidding Program (CBP)
- 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
- 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.