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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.

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.

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.

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
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Potential Issues with PS&R Report 118 Medicare Days

We have observed issues with the Medicare Managed Care days from PS&R Report 118, while working with numerous providers on recent cost report filings. We recommend all providers review any recently generated PS&R summary reports to ensure there are no issues with the Medicare Managed Care days from PS&R Report 118 and potentially re-run new PS&R summary reports to correct any issues.
CMS recently released 05.15.02, addressing PS&R Enhancement 1319 (PS&R updated to purge Rejected claims in conjunction with CR 12251). The following is a description of the issue/resolution:
“Prior to 10/4/2021, FISS was sending rejected claims to PS&R in the Paid Claim File (PCF). The rejected claims caused discrepancies between the Medicare Days and Accommodation Units on the PS&R 118 Report which in turn had the potential to cause an overstatement of Medicare Days on provider cost reports. Due to this problem, CMS issued CR 12251, instructing FISS to no longer send rejected claims to PS&R (with exception of certain RAC PIP non-paid claims). FISS implemented this CR on 10/4/2021 which resolved the issue for prospective claim loading/reporting into PS&R. However, the historical rejected claims which were loaded into PS&R still needed to be purged (made to no longer be reportable) such that they no longer caused the discrepancy described above on PS&R reports. With the implementation of this enhancement, all Rejected claims have been purged from PS&R reporting.”
Please reach out to Matthew Beymer at or Sherry Collins at for any additional cost report questions. They can also be reached at (888) 514-9312.
Thank you,
Toyon Associates, Inc.
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Reminder: Register here to participate in Toyon’s open CARES PRF webinar Wednesday 9/15 at 10 AM PDT





New $25.5 billion in PRF

Re-Determination for PRF Phase 3 Eligibility

Grace Period through November 30 for PRF Period 1 Reporting

1. New $25.5 billion in PRF
Last Friday, HHS announced $25.5 billion in PRF to eligible healthcare providers. The $25.5 billion is split between $17 billion in Phase 4 payments and $8.5 billion in payments to Rural Medicaid providers. The application portal will open on September 29, 2021.   
HHS established a Future Payments Webpage with further information on the application and payment methodologies. Providers will apply for both Phase 4 and Rural payments in a single application. HHS recommends providers gather supporting documentation, such as most recent tax documents and financial statements for the second half of calendar year (CY) 2020 and the first quarter of CY 2021 in preparation to file the application for this funding.
Phase 4 $17 billion: Approximately $12.75 billion (75%) is based on revenue losses and COVID-related expenses. HHS will determine the exact amount after analyzing all applications. No provider will receive a Phase 4 payment that exceeds 100% of their losses and expenses. This funding will:
  • Be based on lost revenues and expenditures between July 1, 2020, and March 31, 2021.  
  • Reimburse large providers a minimum payment based on a percentage of their lost revenues and COVID-related expenses.
  • Fund medium and small providers with a base payment plus a supplement, with small providers receiving the highest supplement.
The remaining ~$4.25 billion (25%) will be allocated as bonus payments based on the amount and type of services provided to Medicaid, CHIP, and Medicare patients. Providers who meet the eligibility (application) criteria will be reimbursed:
  • Based on an HHS calculation pricing Medicaid and CHIP claims data at Medicare rates [1].
  • A minimum payment for providers serving any patients living in Federal Office of Rural Health Policy-defined rural areas with Medicaid, CHIP, or Medicare coverage. HRSA’s tool at Rural Health Grants Eligibility Analyzer provides insight into qualifying rural areas. 
Rural PRF $8.5 billion: HHS is also preparing to disperse $8.5 billion in payments to rural providers from the American Rescue Plan (ARP). Rural payments will be based on the amount of Medicaid/CHIP and Medicare services provided to patients living rural areas as defined in HRSA’s tool – Rural Health Grants Eligibility Analyzer. HRSA will price payments at Medicare rates for Medicaid/CHIP patients. Eligible rural providers may be considered for both Phase 4 and ARP Rural payments.
2. Re-Determination for PRF Phase 3 Eligibility
Providers who believe their PRF Phase 3 payment eligibility was erroneously determined will have a forthcoming opportunity to request a reconsideration. HHS provided a detailed methodology for providers to evaluate and further assess whether initial Phase 3 payments were correctly determined. HHS advises providers to email if it is believed Phase 3 payment was calculated incorrectly, or to be notified when more information becomes available on the Phase 3 reconsiderations process.
HHS’s detailed Phase 3 methodology includes seven steps:
A. Calculating 2 percent of Annual Patient Care Revenue
B. Calculating initial Loss Ratio and Provider-Type Loss Ratios
C. Capping Loss Ratios and other pre-payment value adjustments
D. Calculating 88 percent of Adjusted Losses
E. Selecting the greater of calculated A or D
F. Deducting all prior PRF payments from result of E
G. Flagging and conducting manual review of flagged potential payments
3. Grace Period Through Nov. 30 for PRF Period 1 Reporting
Mentioning COVID surges and natural disasters around the country, HHS posted on the PRF website a 60-day grace period for Period 1 reporting. Providers unable to meet the September 30 deadline for Period 1, are allowed to “come into compliance” with PRF Period 1 submissions through November 30. HHS strongly encourages providers to complete their Period 1 report in the PRF Reporting Portal by September 30, 2021. HHS will not recoup or apply other enforcement actions during the 60-day grace period (October 1 – November 30, 2021).
Toyon’s Take
HHS’s commitment to over $25 billion in PRF is much needed to the provider industry and exhausts a great deal of the remaining balance of CARES funding. Phase 4 may have some semblance of Phase 3 in perhaps measuring operating margins (as HHS recommends providers gather supporting documentation, such as most recent tax documents and financial statements for the second half of CY 2020 and the first quarter of CY 2021). Operating margins comparing the latter half of CY 2020 vs. latter half of CY 2019, as well as a measurement of the first quarter of 2021 vs. the first quarter of 2019 [2] may be evaluated as part of Phase 4. In this round however, HHS is further prioritizing funding based on hospital size [3] and payer mix (e.g., pricing eligible providers’ Medicaid and CHIP claims at Medicare rates). Other funding (e.g., base-funding amounts for large, medium and small providers) may be based on a pro-rata formula, similar to other calculations applied throughout the PRF. 
The redetermination of Phase 3 eligibility is great news for many providers looking for reconsideration of these payments. Toyon is in the process of updating a model to assist with Phase 3 redeterminations and will be sharing it with our clients over the coming weeks.
Lastly, the 60-day grace period is certainly welcome for many providers. However, uncertainty remains concerning the impact of being “out of compliance” as well as PRF portal availability from October 1 through November 30. Toyon will share any additional information on these concerns if it becomes available.
Please feel free to contact Fred Fisher at with any questions. Thank you. 
[1] HHS notes there will be some limited exceptions for some services provided predominantly in Medicaid and CHIP.
[2] Consolidated Appropriations Act, 2021 (H. R. 133—740) “any funds recovered from health care providers after the date of enactment of this Act, shall be for any successor to the Phase 3 General Distribution allocation to make payments to eligible health care providers based on applications that consider financial losses and changes in operating expenses occurring in the third or fourth quarter of calendar year 2020, or the first quarter of calendar year 2021, that are attributable to coronavirus…”
[3] Details (e.g., beds, discharges, visits, NPSR, etc.) related to the measurements used to determine small, medium and large providers are still to be determined.  
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