Health Law Daily CMS proposes $6B OPPS increase, touts price transparency provisions
Tuesday, July 30, 2019

CMS proposes $6B OPPS increase, touts price transparency provisions

By Sheila Lynch-Afryl, J.D., M.A.

CMS sought to increase reimbursement under the OPPS and ASC PPS and proposed to create new regulations on price transparency.

Total payments under the proposed hospital outpatient prospective payment system (OPPS) update for calendar year (CY) 2020 would be approximately $79 billion, an increase of $6 billion compared to estimated CY 2019 OPPS payments. In the advance release of the OPPS proposed rule, which will be published in the Federal Register on August 9, 2019, CMS would also increase payments to ambulatory surgical centers (ASCs) by approximately $200 million for CY 2020. Comments on the proposed rule are due September 27, 2019.

OPPS update. CMS proposed to increase payment rates under the OPPS by an increase factor of 2.7 percent, which is based on the proposed hospital inpatient market basket percentage increase of 3.2 percent for inpatient services paid under the hospital inpatient prospective payment system (IPPS), minus the proposed multifactor productivity adjustment of 0.5 percentage point mandated by section 3401 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

Price transparency. Pursuant to section 2718(e) of the Public Health Service Act, as added by ACA section 1001, and President Donald Trump’s executive order on price and quality transparency, CMS proposed to add new 45 C.F.R. Part 180, which includes regulations on price transparency.

Off-campus provider-based departments. In the 2019 OPPS final rule (83 FR 58818, November 21, 2018), CMS announced that it would apply an amount equal to the site-specific physician fee schedule payment rate for nonexcepted items and services furnished by a nonexcepted off-campus provider-based department (PBD) for the clinic visit service (HCPCS code G0463), when provided at an off-campus provider-based department excepted from Soc. Sec. Act §1833(t)(21) (see CMS extends site-neutral payment policy but increases payment under OPPS, November 26, 2018). CMS began phasing in this policy in 2019, and in 2020 it will complete the phase-in. In December the American Hospital Association filed suit against CMS claiming that CMS exceeded its statutory authority by setting the same rate of payment for clinic visit services provided at both excepted and nonexcepted PBDs (see Top 5 Medicare cases from 2018, December 19, 2018).

340B drugs. In December, a D.C. district court concluded that CMS exceeded its statutory authority by adjusting the Medicare payment rates for drugs acquired under the 340B program to ASP minus 22.5 percent (see 2019 340B Reimbursement rate unlawful as 2018 rate, May 9, 2019). In the wake of this decision, CMS sought public comments on the appropriate OPPS payment rate for 340B-acquired drugs for CY 2020 and for purposes of determining the remedy for CYs 2018 and 2019. CMS also sought feedback on how to structure the remedy for CYs 2018 and 2019.

Quality reporting. For the hospital outpatient quality reporting (OQR) program, CMS proposed to remove OP-33: External Beam Radiotherapy for Bone Metastases for the CY 2022 payment determination and later. For the ASC quality reporting program, CMS proposed to adopt a new measure, ASC-19: Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers, beginning with the CY 2024 payment determination and later.

MainStory: TopStory NewsStory ReimbursementNews HealthCareReformNews CMSNews ASCNews HealthReformNews PartBNews OPPSNews QualityNews

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