CMS Proposes Rule on OPPS and ASC Payment Systems

Along with the proposed 2015 Medicare Physician Fee Schedule, CMS released a proposed rule to the 2015 Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Medicare Ambulatory Surgical Center (ASC) payment system.

The rule would shift hospital outpatient payments from the current hybrid approach, to a prospective payment system that bundles payments for certain primary procedures. Under the proposal, the amounts and factors used to determine the payment rates for Medicare services under the OPPS and those paid under the ASC payment system would be altered.

Of noteworthy mention, the rule contains provisions on the services covered by the Ambulatory Payment Classification (APC) policy and on Off Campus Provider-Based Departments. The rule proposes adopting a new comprehensive APC policy that would bundle all supplies and supportive services associated with specific “primary services” into one comprehensive payment.

Break Away from the Static

As a result of hospital-physician consolidations, many physician offices bill Medicare at the higher, hospital rate due to their affiliation with the hospital. Therefore, CMS proposes to begin collecting data on services that are covered in an off-campus provider-based department by requiring hospitals and physicians to report a modifier for those services.

Other proposed changes include:

  • Setting the outlier threshold for hospital outpatient payments at a cost that exceeds 1.75 times the service payment amount and exceeds the APC payment amounts plus $3,100.
  • No longer requiring a physician to certify Medicare Part A inpatient hospital stays to reduce administrative burdens.
  • Consolidating the five Type A and five Type B ED codes into one Type A and one Type B code.
  • Updating and refining the requirements for the Hospital Outpatient Quality Reporting Program and the ASC Quality Reporting Program.
  • Establishing a formal process for recovering overpayments for erroneous payment data submitted by an MA organization or Part D sponsor as well as establishing an appeals process that would review CMS’s determinations of erroneous payment data.

CMS is asking that comments on the proposed rule be submitted by September 2, 2014. The HBMA Government Relations Committee is currently analyzing the proposed rule and assessing the need for HBMA to submit comments. Instructions for submitting comments either electronically or hard copy can be found in the link above.

As always, ADVOCATE will keep you updated on this and all issues impacting radiology as they become available.

Best regards,
Kirk Reinitz, CPA