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CMS proposes site-neutral payments for hospital outpatient setting


Certain procedures conducted in the hospital outpatient setting could see a reimbursement cut to levels paid for under the physician fee schedule if a proposal introduced by the Centers for Medicare & Medicaid Services is finalized.

Seema Verma CMS

Seema Verma

In the proposed update to the Outpatient Prospective Payment System (OPPS) for 2019, released July 27 and scheduled to be published July 31 in the Federal Register, the CMS is proposing to apply a physician fee schedule–equivalent for the clinic visit service when provided at an off-campus, provider-based department that is paid under the OPPS.

“The clinic visit is the most common service billed under the OPPS and is often furnished in the physician office setting,” the CMS said in a fact sheet detailing its proposal.

According to the CMS, the average current clinical visit paid by the CMS is $116 with $23 being the average copay by the patient. If the proposal is finalized, the payment would drop to about $46 with an average patient copay of $9.

“This is intended to address concerns about recent consolidations in the market that reduce competition,” CMS Administrator Seema Verma said during a July 25 press conference.

The American Hospital Association already is pushing back on this proposal.

“With today’s proposed rule, CMS has once again showed a lack of understanding about the reality in which hospitals and health systems operate daily to serve the needs of their communities,” AHA Executive Vice President Tom Nickels said in a statement. “In 2015, Congress clearly intended to provide current off-campus hospital clinics with the existing outpatient payment rate in recognition of the critical role they play in their communities. But CMS’s proposal runs counter to this and will instead impede access to care for the most vulnerable patients.”

However, Farzad Mostashari, MD, founder of the health care technology company Aledade and National Coordinator for Health IT under President Obama, suggested that this could actually be a good thing for hospitals.

“The truth is that this proposal could help hospitals be more competitive in value-based contracts/alternative-payment models, and they should embrace the changes,” he said in a tweet.

The OPPS update also includes proposals to expand the list of covered surgical procedures that can be performed in an ambulatory surgical center, a move that Ms. Verma said would “provide patients with more choices and options for lower-priced care.”

“For CY 2019, CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the [covered procedure list] and is proposing to add certain cardiovascular codes to the ASC [covered procedure list] as a result,” the CMS fact sheet notes.

The CMS also will review all procedures added to the covered procedure list in the past 3 years to determine whether such procedures should continue to be covered.

In addition, the OPPS is seeking feedback on a number of topics.

One is related to price transparency. The agency is asking “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other charges are needed to empower patients,” according to the fact sheet.


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