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Tag: Pricing Transparency

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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OPPS Final Rule – CY 2019

In This Edition:

  • CY 2019 Medicare OPPS Final Rule
  • Pricing Transparency Revisited
  • Hospital Value Based Purchasing Data Published
  • Hospital-Specific Rate Refresher

OPPS Final Rule – CY 2019
CMS-1695-FC drafted on 11/2/2018; Published in the Federal Register on 11/21/2018 and corrected notice issued on 11/30/2018

On November 2, 2018, the Centers for Medicare & Medicaid Services (CMS) finalized changes that remove unnecessary and inefficient payment differences between certain provider and supplier types so patients can have more affordable choices and options. The final rule with comment period updates and revises policies under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System.

The polices in the calendar year (CY) 2019 OPPS and ASC Payment System final rule with comment period will further advance the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, and significant burden reduction so that hospitals and ambulatory surgical centers can operate with better flexibility and patients have access to the tools they need to become active healthcare consumers.

Overall, the final rule is projected to result in an estimated increase of $360M (or 0.6%) in payments to providers, ranging from -1.6% decreases for rural hospitals in the New England region up to 1.6% increases for rural hospitals in the West South Central region.

For more information regarding this Final Rule, see below:

Fact Sheet Link

Federal Register Link

Medicare OPPS Base Rates
CMS is proposing a base rate increase of 1.35% for hospitals that submit OQR quality data and 2.1% for ASCs that submit ASCQR quality data.

APC Changes
As expected, CMS has finalized the 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 created three new comprehensive APCs (C-APCs) for ears, nose, and throat (ENT) and vascular procedures.  CMS will also remove four 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 finalizing several changes to the OQR reporting in an effort to reduce burdens on hospitals, including the removal of 8 measures from the OQR (1 from CY2020 and 7 from CY2021).  CMS will also remove the three recently revised pain communication questions, starting with services on Oct. 1, 2019, to address concerns that providers might feel pressure to offer opioids in order to raise survey scores.

Click here for a table of the 8 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 60% less than the OPPS rate.)  CMS will phase in this policy by paying 70% of the OPPS rate in 2019, then reducing payment to 40% of the OPPS rate in 2020 and future years.  CMS estimates that the impact of this change is expected to reduce reimbursement to hospitals by $380M in FY2019 and $760M in FY2020 and beyond.

Restricting “Clinical Families of Services” – Cancelled:  CMS decided not to finalize its requirement that excepted off-campus PBDs be limited from expanding services to 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 have been paid at the reduced PFS rate applied to non-excepted off-campus PBDs.  New items or services within a clinical family of service would have continued to be paid under OPPS, as this would be considered a “service expansion.”  Even though this policy was not finalized, CMS indicated that it has the authority to do so and will continue to monitor these PBDs and service growth.

New “ER” Modifier:  Finally, CMS will require a new “ER” modifier to identify services in off-campus ER departments.  The modifier would be reported on the UB-04 form and would be required on every line for outpatient services furnished in an off-campus provider-based emergency department.  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 has changed the packaging policy for certain drugs.  CMS will also change the payment for separately payable drugs for non-excepted off-campus PBDs to the same lower Average Sales Price (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.  Rural 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.

Other News

Pricing Transparency Revisited – Action Required by 1/1/2019
CMS is updating their guidelines regarding the requirements to comply with Section 2718(e) of the Public Health Service Act for hospitals to make public a list of the hospital’s standard charges. Previously issued guidelines required hospitals to 1) make public a list of standard charges (whether that be the chargemaster itself or in another form of the hospital’s choice), or 2) make known the hospital’s policies for allowing the public to view a list of those charges in response to an inquiry.

Effective January 1, 2019, CMS is revising their guidelines to remove the requirement to make known the hospital’s policies for allowing the public to view a list of those charges in response to an inquiry. Hospitals will now be required to make available a list of their standard charges via the internet in a machine-readable format and require that these lists be updated at least annually.

 In the proposed rule, CMS solicited comments on various questions to include defining standard charges, type of information beneficial to patients, informing patients of their out-of-pocket costs, and greater transparency around patient obligations. In the final rule, CMS did not respond directly to public comments but published a separate FAQ document, which can be accessed here.

Toyon’s Take:  Toyon recommends the following actions to comply with this change:

  • List the charges at gross amounts (i.e., not adjusted for discounts to third-party payers, charity, self-pay, etc.)
  • Calculate the average charge per case for each MS-DRG and include with the list of standard charges (Use FY 2011-2016 publicly available info as a guide at this link)
  • For services subject to variable pricing (e.g., drugs, supplies, and implants subject to an internal mark-up policy that are variable to acquisition price), develop an average charge from the most recent period (e.g., quarter, year)
  • Publish the list in a machine readable format (e.g., txt, csv, xlm, etc.). Note:  PDF is not considered an acceptable format.
  • Update at least annually the publicly available chargemaster
  • Include an advisory statement that the published charges are to be used as a guide and that actual charges incurred and patient obligation may differ
  • The format is at the hospital’s discretion, and CMS did not specifically address the inclusion of hospital charge codes and CPT/HCPCS

For additional information, please contact Robert Howey at

 Hospital Value-Based Purchasing Program Update for FFY 2019
On December 3, 2018, CMS released the final hospital value-based purchasing (VBP) incentive payment adjustment factors in Table 16B on its website for FFY 2019. The payment factors are effective for Medicare discharges on or after October 1, 2018, and are applied to the adjusted base operating MS-DRG payment. Each participating hospital’s payment rate is inclusive of a 2 percent contribution to the VBP payment pool ($1.9B) and adjustment factors greater than 1.0 represent those receiving payments above their contribution.

The payment factors are based on each hospital’s total performance score (TPS) measured on four equally weighted domains: Clinical Care (Mortality), Patient and Caregiver-Centered Experience, Patient Safety, and Efficiency/Cost Reduction. The breakeven TPS score for FFY 2019 was 35.15 (up from 34.60) and over 55 percent of hospitals will receive higher Medicare payments from the previous year. The highest performing hospital will receive a net increase in IPPS payments of 3.67 percent, and the lowest performing hospital will incur a net decrease in IPPS payments of 1.59 percent.

Click here for a table of estimated VBP payment impacts to each hospital.

For additional information, please contact Robert Howey at

Hospital-Specific Rate Updates – A Refresher
When calculating a Sole Community or Medicare Dependent Hospital’s hospital-specific rate (HSR) each year, remember that any hospital-specific adjustment factor (e.g., IQR or EHR reduction factor) is only applicable for discharges occurring during that Federal Fiscal Year.  Those reduction factors are not cumulative in nature and should not be carried forward.

The HSR should be tabulated each year by adjusting the hospital’s most recent base period rate by the full, non-reduced cumulative update factors applicable to all hospitals for each fiscal year since the latest rebasing.  And then only for the current Federal Fiscal Year should any hospital-specific adjustment factors be applied to the hospital for that one year.

For additional information, please contact Ron Knapp at

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