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Category: Medicare

Medicare Graduate Medical Education and Organ Acquisition Payment Policy Changes

On Monday December 27, CMS published Federal Register / Vol. 86. No. 245 [CMS–1752–FC3. This Final Rule with comment period includes new teaching slots for graduate medical education, modifications to organ acquisition reimbursement, and postpones potential changes related to Section 1115 waiver days for empirical DSH payments. February 25 is the deadline to submit comments to CMS for the issues (discussed below) whereby CMS is seeking feedback. 

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CARES PROVIDER RELIEF FUND (PRF) Phase 4 Funding Update

 

 

1.  Begins Distributing Phase 4 Payments

2.  Toyon’s Template is Available to Assist Providers Reconcile Phase 4 Base Payments.

3.  Providers have until December 20, 2021 (11:59 PM ET) to correct errors related to PRF Reporting Period 1.

 

 
Toyon is pleased to provide this update on the CARES Provider Relief Fund (PRF). For more information, please contact Fred Fisher at 888.514.9312, fred.fisher@toyonassociates.com.
 
1.  HRSA is Distributing Phase 4 Funds
Today, December 16, 2021, HRSA began distributing $9 billion, out of $17 billion, in Phase 4 Funding to more than 69,000 providers.    
 
Phase 4 Base Payments
75% of Total Phase 4 Funding ($12.75 billion)
 
Phase 4 Funding is broken down into two parts, with the first being the Base Phase 4 payment. Phase 4 base payments are adjusted depending on annual patient care revenue. Funding percentages range from 20% (for large providers) to 45% (for small providers). These funding percentages are significantly less than the 88% funding percentage applied in Phase 3.
  • Small sized providers receive 45% of Phase 4 losses. Small providers have less than or equal to $10 million in annual patient care revenue. The current average payment is $58,000.
  • Medium sized providers receive 25% of Phase 4 losses. Medium providers have more than $10 million and less than $100 million in annual patient care revenue. The current average payment is $289,000.
  • Large sized providers receive 20% of Phase 4 losses. Large providers have $100 million or more in patient care revenue. The current average payment is $1.7 million.
HRSA’s Phase 4 methodology takes additional steps to flag aberrant data, and offset losses for “PRF payments not previously deducted in Phase 3.” Toyon believes HRSA is carrying forward PRF in excess of Phase 3 losses and reducing Phase 4 payments by this amount.
 
Bonus Payments
25% of Total Phase 4 Funding (~$4.25 billion)
 
In addition to the Base Phase 4 payment, HRSA is also disbursing “bonus” Phase 4 payments. Similar to rural payments from the American Rescue Plan (ARP), Phase 4 bonus payments are based on Medicare, Medicaid, and CHIP administrative claims data from January 1, 2019 through September 30, 2020 (Phase 4 bonus payments uses all claims as compared to the Rural ARP which uses rural claims). 
 
HRSA calculates Phase 4 bonus payments by determining the difference between payments at Medicaid rates versus payments at Medicare rates. The difference in payments is then reduced in a budget neutral manner to fit “the portion of funding set aside for bonus payments.” Based on eligibility criteria to apply for Phase 4 payments, it is believed HRSA used inpatient and outpatient claims from both Fee for Service and Managed Care payors. 
 
2.  Toyon’s Template to Reconcile Phase 4 Base Payments
Please feel free to use Toyon’s template to reconcile Base Phase 4 payments. The template is available here for download on Toyon’s website. 
  • The first of the two tabs is populated with hypothetical information to show how the provider’s Phase 4 payment was determined. 
  • The second tab is a template for provider input. 
  • To use this tab, input information into the grey cells and the formulas will calculate throughout the spreadsheet. 
  • Please note the current template utilizes thresholds to determine aberrant data, and potential “flags”, from thresholds established in Phase 3.  
  • To avoid amounts from being adjusted from any flags, please ensure “Yes” is populated in key columns AD and AJ. 
3.     CARES PRF Reporting Period 1 Correction and Period 2 Reporting
The PRF Period 1 Reporting Portal is now open through December 20, 2021 (11:59 PM ET) for any provider that still needs to register or submit | correct information related to PRF Reporting Period 1. PRF recipients looking to correct an error must contact the Provider Support Line (866-569-3522) to gain access to their submitted report.
 
The PRF Period 2 Reporting Portal is slated to open on January 1, 2022 and close March 31, 2022. PRF Reporting Period 2 will cover PRF amounts received from July 1, 2020 through December 31, 2020 and expenses and lost revenues incurred during the “period of availability” of January 1, 2020 through December 31, 2020 (excluding any amounts that were already applied towards PRF Reporting for Period 1). 
 
Toyon is committed to apprising providers with important reimbursement updates and will keep you updated with the latest COVID-19 funding and documentation news. Please feel free to visit Toyon’s COVID-19 Resources for more information.  
 
Thank you
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Final Payment Rules – Calendar Year (CY) 2022

On November 2, 2021, the Centers for Medicare & Medicaid Services (CMS) issued the final rules for Calendar Year (CY) 2022 Outpatient Prospective Payment System (OPPS), CY 2022 Physician Fee Schedule, and CY 2022 Home Health PPS.

KEY UPDATES FROM THE CY 2022 OPPS FINAL RULE:
CY 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule (CMS-1753-FC).
 
OPPS & ASC Payment Rates
Both the OPPS and ASC payment rates for hospitals that meet applicable quality reporting requirements will be increased by 2.0 percent (2.7 percent less 0.7 percentage point productivity adjustment.
 
Price Transparency
Proposed Increase in Civil Monetary Penalties (CMP) for noncompliance will be scaled by bed size (range $109,500 to $2,007,500 per hospital). Smaller hospitals with 30 or fewer beds are subject to a fine equal to $300 per day. Hospitals with a bed count between 31-550 beds are subject to a fine between $310 to $550 per day with a maximum penalty $2,007,500. Hospitals with a bed count of 551 or greater beds, are subject to a fine equal to $2,007,500 per hospital.
 
CMS is also requiring machine-readable files are accessible for automated searches and direct downloads.
 
Toyon’s Take
These fines emphasize CMS’s push to provide public access to pricing information.
 
Use of CY 2019 Claims Data for CY 2022 OPPS/ASC Ratesetting
CMS believes the best available data for projecting expected cost and OPPS/ASC payment derives from calendar year 2019, prior to the COVID-19 Public Health Emergency (PHE). Conventionally, CMS would have used the most recent data (from 2020) for ratesetting.
 
Toyon’s Take
Toyon recommends providers regularly evaluate CY 2022 OPPS/ASC payments to ascertain the reasonableness of CMS’s projection that CY 2022 cost and volumes will be more reflective of 2019 levels as compared to 2020. When areas of the country “normalize” from COVID-19 PHE, then it is best to use data from prior to the outbreak to project CY 2022 OPPS/ASC payments. Notably, CY 2020 data may not be used in future rates.
 
Changes to the Medicare Inpatient Only (IPO) List
In CY 2022 CMS will add back all codes to the IPO list, except CPT codes 22630 (Lumbar spine fusion), 23472 (Reconstruct shoulder joint), 27702 (Reconstruct ankle joint) and their corresponding anesthesia codes. Also, the planned elimination of the IPO list will be put on hold until further notice. See this link.
 
Toyon’s Take
Requiring certain services as inpatient only is a noteworthy change in course from the CY 2021 OPPS/ASC final rule initially eliminating 298 services from the IPO list. CY 2021 was also scheduled to be year one of a three-year process to phase out the entire IPO list. However, CMS listened to stakeholder comments and agrees patient safety is the main concern. Medicare continuously desires to provide their beneficiaries a choice, therefore is using additional time to review procedures and outcomes of IPO services.
 
OPPS and 340B
CMS is continuing to pay hospitals 22.5 percent less the Average Sales Price (ASP) for select 340B drugs.
 
Click here for the link to the display copy of the OPPS/ASC final rule; the document is scheduled to be published in the federal register on 11/16/2021.

 
KEY UPDATES FROM THE CY 2022 PHYSICIAN FEE SCHEDULE FINAL RULE:
CY 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule (CMS-1751-F).
 
Telehealth Expansion for Behavioral Health
The COVID-19 PHE shows gaps in healthcare delivery and the need for technology to treat patients, especially patients located in remote communities. CMS, in this rule, is eliminating barriers and will allow patients to access telehealth services in their homes, for the diagnosis, evaluation, and treatment of mental health disorders.
 
Medicare will also cover mental health visits in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) through telehealth technologies, including audio only calls.
 
Increasing Access to Physician Assistants’ (PA) Services
CMS will institute a change that will authorize Medicare to make direct Medicare payments to Physician Assistants (PAs) for professional services they furnish under Part B. Beginning January 1, 2022 PAs are permitted to bill Medicare directly. This change allows greater access to care for Medicare beneficiaries. 
 
Medicare Ground Ambulance Data Collection System
CMS finalized changes to the Medicare Ground Ambulance Data Collection System including:
  • Finalizing a new data collection period beginning between January 1, 2023, and December 31, 2023, and a new data reporting period beginning between January 1, 2024, and December 31, 2024, for selected ground ambulance organizations in year three;
  • Revising the timeline for when the payment reduction for failure to report will begin aligning the timelines for the application of penalties for not reporting data; and
  • Amending to the Medicare Ground Ambulance Data Collection Instrument. This will improve its clarity and make the instrument less burdensome to complete.

Click here for the link to the display copy of the Physician Fee Schedule; the document is scheduled to be published in the federal register on 11/19/2021.


 
KEY UPDATES FROM THE CY 2022 HOME HEALTH PPS FINAL RULE:
CY 2022 Home Health Prospective Payment System Rate Update Final Rule (CMS-1747-F & CMS-5531-F)
 
CY 2022 Updates to the Home Health (HH) PPS rates
The final rule updates CY 2022 Medicare Home Health (HH) payment rates by 2.6 percent and uses the latest Core-Based Statistical Area (CBSA) delineations as well as the latest available pre-reclassified hospital wage data under the Medicare IPPS.

CY 2022 Updates to Home Health Quality Reporting Program
The Home Health QRP is a program that reports quality data to CMS. All HHAs that do not meet reporting requirements receive a 2-percentage point reduction to their annual market basket percentage update for the respective calendar year. In this final rule the OASIS-based measure is removed as it did not demonstrate any meaningful difference in performance. Two claim-based measures will be replaced with a new measure that surrounding attribution and associated with desired patient outcomes.
 
CMS is finalizing its proposal that effective January 1, 2023, HHAs begin collecting data on the Transfer of Health Information to Provider-Post Acute Care measure, the Transfer of Health Information to Patient-PAC measure, as well as six categories of standardized patient assessment data elements, to support the coordination of care.
 
Click here for the link to the display copy of the Home Health PPS update; the document is scheduled to be published in the federal register on 11/9/2021

For questions regarding these rules, please contact Scott.Besler@toyonassociates.com.
 
 
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