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Just when the procedures thought they were out(patient), CMS pulls them back in(patient).

Last year, in the final CY 2021 Outpatient PPS rule, CMS announced its intention to eliminate the Inpatient Only (IPO) List by January 1, 2024. The IPO list featured more than 1,700 procedures that were surgically invasive or required more than 24 hours of post-operational recovery time. As a result, any procedure on the list would only be paid for by Medicare on an inpatient basis.

With the CY 2021 rule, those procedures would be released to outpatient providers in stages, allowing physicians to clinically determine whether inpatient admission was indicated for a particular procedure.

However, in the proposed CY 2022 Outpatient PPS rule, announced on July 19, 2021, CMS reversed that decision and announced that it will now keep the IPO List, reinstating the 298 procedures that were removed by the 2021 rule. CMS said it was responding to concerns from stakeholders about patient safety. In particular, CMS indicated that the 2021 rule removed the procedures on too steep of a timeline. The agency said it wanted to provide “greater consideration of the impact removing services from the list has on beneficiary safety and to allow providers impacted by the COVID-19 PHE additional time to prepare to furnish appropriate services safely and efficiently before continuing to remove large numbers of services from the list.”Continue Reading CMS Gives the IPO List the Godfather 3 Treatment

On May 3, 2021, the Centers for Medicare & Medicaid Services (CMS) published an 81-page final rule to both extend and change the Comprehensive Care for Joint Replacement (CJR) model. We previously reported on the proposed rule here. The CJR model was initially implemented by way of notice-and-comment rulemaking in April 2016; the recent…

The annual Advisory Panel on Hospital Outpatient Payment meeting will be held on August 19-20, 2019, the Centers for Medicare & Medicaid Services (CMS) has announced.  The Panel is charged with advising CMS on outpatient prospective payment system (OPPS) ambulatory payment classification clinical integrity and weights, along with hospital outpatient therapeutic services supervision issues. …

CMS is holding its annual Advisory Panel on Hospital Outpatient Payment meeting on August 21-22 2017.  The purpose of the Panel is to advise HHS and CMS on ambulatory payment classification (APC) clinical integrity and weights and hospital outpatient therapeutic services supervision issues.  Topics that may be considered during the meeting include:

  • Whether procedures

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Hospitals are facing a March 8, 2017 deadline to begin using the new Medicare Outpatient Observation Notice (MOON) to inform Medicare beneficiaries when they are outpatients receiving observation services and not inpatients of the hospital.  The notice is required by the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act). 

Included in the 21st Century Cures Act are numerous changes to Medicare and Medicaid policies, including provisions with significant reimbursement impacts for certain types of Medicare providers and suppliers, along with changes intended to reduce the regulatory and administrative burdens associated with the use of electronic health records.  Furthermore, the law once again expands the…

CMS has published its final rule with comment period updating the Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System rates and policies for CY 2017.  CMS will accept comments on a limited number of provisions until December 31, 2016.

Major provisions impacting outpatient hospital department services include the following: 
Continue Reading CMS Finalizes Medicare OPPS, ASC Rates and Policies for 2017

CMS has published its proposed rule to update the Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System rates and policies for CY 2017. CMS proposes a 1.55% OPPS update, reflecting a 2.8% market basket increase, which is partly offset by a -0.5% multifactor productivity (MFP) adjustment and an additional 0.75% reduction (both mandated by the Affordable Care Act). CMS expects that overall OPPS payments would increase by 1.6%, or $671 million, compared with 2016 levels, because of the proposed changes in the rule.  Hospitals that fail to meet the Hospital Outpatient Quality Reporting (OQR) Program reporting requirements are subject to an additional reduction of 2.0 percentage points.  The actual update for individual procedures can vary dramatically, however, based on changes in ambulatory payment classification (APC) assignment and other policies in the proposed rule.  Other major provisions of the proposed rule include the following:  
Continue Reading CMS Proposes Update to Medicare OPPS, ASC Rates and Policies for 2017

A new OIG report examines CMS’s oversight of Medicare billing by provider-based facilities – that is, facilities that operate under the ownership, administrative, and financial control of a hospital and meet other requirements, and that bill as an outpatient department of the hospital rather than a freestanding facility. The OIG observes that Medicare payments under…

The House of Representatives has approved H.R. 5273, the “Helping Hospitals Improve Patient Care Act of 2016,” as amended by the Ways and Means Committee in May. As previously reported, while the bill focuses on Medicare payment policies pertaining to hospitals (including long term care hospitals and hospital outpatient departments), it also addresses…

The House Ways and Means Committee has approved an amended version of H.R. 5273, the “Helping Hospitals Improve Patient Care Act of 2016.”  While most of the provisions address Medicare payment policies pertaining to hospitals (including long term care hospitals (LTCHs) and hospital outpatient departments), certain other reimbursement policies, including Medicare Advantage and physician payment…

The House Energy and Commerce Committee is seeking input on Section 603 of the Bipartisan Budget Act of 2015, which established a site-neutral payment policy for newly-acquired, provider-based, off campus hospital outpatient departments (HOPD) after November 2, 2016.  In an open letter to the health care community, the Committee explains the origins of the policy, noting that it was enacted as a result of concerns that the Medicare hospital outpatient prospective payment system paid more for the same services provided at HOPDs than in other settings, such as an ambulatory surgery center, physician office, or community outpatient facility.   The letter discusses evidence the Committee considered in establishing this policy, but notes that the Committee has received significant feedback on this provision since enactment, with concerns raised about the provision’s potential impact on hospitals, beneficiaries, and providers.  The Committee has received a range of recommendations from the public, with stakeholders urging the Committee to:
Continue Reading House Energy & Commerce Committee Seeks Comments on Medicare Site-Neutral Payment Policies

The Government Accountability Office (GAO) has issued a report examining trends in “vertical consolidation” — hospital acquisition of physician practices or hiring of physicians as salaried employees – and the impact on Medicare spending. According to the GAO, the number of vertically consolidated hospitals increased from about 1,400 to 1,700 from 2007 through 2013, while…

On November 2, 2015, President Obama signed into law H.R. 1314, the “Bipartisan Budget Act of 2015” (BBA).  The two-year, $80 billion budget/debt-ceiling deal is funded in part by several significant Medicare and Medicaid policies, including an extension of Medicare sequestration, changes to Medicare payment for services provided in “new” off-campus hospital outpatient departments (OPDs), and extension of inflation-based Medicaid drug rebates to generic drugs.
Continue Reading Bipartisan Budget Law Extends Medicare Sequestration, Includes Medicaid Drug Rebate, Off-Campus Hospital Outpatient Department, CMP Inflation Policies

The OIG has issued a policy statement clarifying the conditions under which hospitals may discount or waive Medicare beneficiary copayment amounts for self-administered drugs (SADs) received in outpatient settings without running afoul of OIG fraud authorities. In particular, the OIG addressed questions that have arisen from a 2003 CMS statement that a hospital’s decision not to bill a beneficiary for SADs that are not covered by the Medicare Part B program (Noncovered SADs) potentially implicates the prohibition on inducements to beneficiaries (section 1128A(a)(5) of the Social Security Act) or the anti-kickback statute (section 1128B(b) of the Act).
Continue Reading OIG Policy Statement Outlines Conditions Under Which Hospitals May Waive Beneficiary Copayments for Outpatient Self-Administered Drugs

Outgoing House Speaker John Boehner and the Obama Administration have reached agreement on a two-year, $80 billion budget/debt-ceiling deal that includes Medicare and Medicaid “offsets” to finance other spending. For instance, while the budget would provide $80 billion in discretionary spending sequestration relief over two years, it would extend Medicare sequestration for an additional year, through 2025. The deal also would:
Continue Reading Pending Budget Deal Includes Medicare Sequestration Extension, Other Medicare/Medicaid Cuts

On August 6, 2015, President Obama signed into law H.R. 876, the Notice of Observation Treatment and Implication for Care Eligibility Act.  The new law requires hospitals to provide written and oral notification to Medicare beneficiaries receiving observation status for more than 24 hours, rather than admitted as inpatients, beginning 12 months after the…

On July 27, 2015, the Senate approved H.R. 876, the Notice of Observation Treatment and Implication for Care Eligibility Act, clearing the measure for the President. H.R. 876 would require hospitals to provide written and oral notification to Medicare beneficiaries receiving observation status for more than 24 hours, rather than admitted as inpatients.
Continue Reading Senate Approves Hospital Outpatient Observation Status “Notice” Act

On July 8, 2015, the Centers for Medicare & Medicaid Services (CMS) published its proposed rule to update the Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System rates and policies for calendar year (CY) 2016.  Perhaps most notably, CMS is proposing a -0.1% OPPS update for 2016, driven mainly by a proposed correction of a $1 billion error the agency made when estimating the extent to which clinical laboratory tests would be packaged (rather than paid separately) under a new policy implemented in 2014. Specifically, the proposed -0.1% update reflects a 2.7% market basket increase, which is partially offset by a -0.6% multifactor productivity (MFP) adjustment and an additional 0.2% reduction (both mandated by the Affordable Care Act), further reduced by a -2.0 percentage point adjustment to recoup the prior $1 billion overestimation of laboratory test packaging. CMS expects that overall OPPS payments under the proposed rule would fall by 0.2%, or $43 million, compared with 2015 levels. Hospitals that fail to meet the Hospital Outpatient Quality Reporting (OQR) Program reporting requirements are subject to an additional reduction of 2.0 percentage points. The actual update for individual procedures can vary dramatically, however. Other highlights of the proposed rule include the following:
Continue Reading CMS Proposes $43 Million CY 2016 Medicare OPPS Rate Cut; Small Increase in ASC Payments

Today CMS published a notice correcting its November 10, 2014 final rule updating the Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System rates and policies for calendar year 2015. In addition to fixing various technical errors (e.g., status indicator and addenda corrections for specific codes), the notice increases…