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  • Washington Highlights

    AAMC Submits Comment Letter on CY 2020 OPPS Proposed Rule

    Mary Mullaney, Director, Hospital Payment Policies
    Andrew Amari, Hospital Policy and Regulatory Specialist
    Phoebe Ramsey, Director, Physician Payment & Quality

    AAMC Submits Comment Letter on CY 2020 OPPS Proposed Rule

    The AAMC Sept. 27 submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) on the calendar year (CY) 2020 Outpatient Prospective Payment System (OPPS) proposed rule.

    In addition to the standard payment update proposals, CMS proposed changes to hospital price transparency requirements, solicited comments on remedies for recent 340B Drug Pricing Program litigation, and proposed to introduce prior authorization requirements for a select group of service categories. The proposed rule also included changes to the Medicare wage index and changes to the inpatient only (IPO) list. Finally, the rule addressed several quality issues, including a request for information (RFI) on incorporating quality information in the agency’s broader price transparency efforts, and the removal of several quality measures.

    Below are highlights of AAMC comments on proposals in the OPPS proposed rule:

    • Requirements for Hospitals to Make Public a List of Standard Charges. CMS proposed requirements on hospitals to make public a list of gross and payer-specific negotiated charges for all items and services, as well as a requirement to post at least 300 shoppable services in a consumer-friendly manner. The AAMC urged CMS to not finalize the proposals, which do not address consumers’ desire for information related to their specific out-of-pocket costs and place significant burden solely on hospitals. Instead, the AAMC suggested CMS work with stakeholders to develop information that will be actionable and understandable to consumers.
    • 340B Drug Pricing Program. CMS proposed to continue paying for drugs acquired through the 340B program at average sales price (ASP) minus 22.5% under OPPS and when furnished at nonexempt, off-campus provider-based departments (PBDs). In addition, CMS solicited comments on potential remedies related to the AAMC’s favorable outcome in the litigation surrounding cuts to the 340B program [see Washington Highlights, Jan. 11]. The AAMC emphasized that the agency should not finalize cuts for CY 2020, as a federal court has found the CY 2018 and CY 2019 cuts exceeded CMS’s authority. Additionally, the AAMC suggested a remedy consistent with its co-litigants: CMS should refund payments to each affected 340B hospital calculated using the “JG” modifier, which identifies claims for 340B-acquired drugs that were reduced under the CY 2018 and CY 2019 hospital OPPS final rules. Providers not adversely affected by the reductions should be held harmless.
    • Site-Neutral Payment Policies. CMS proposed to continue cuts to provider reimbursement for certain clinic visits (Healthcare Common Procedure Coding System [HCPCS] code G0463) at excepted off-campus provider-based departments (PBDs). The AAMC, along with others litigated this matter [see Washington Highlights, Dec. 7, 2018], and the federal district court recently issued a favorable decision for hospitals, confirming that CMS exceeded its authority in making these cuts. The AAMC, consistent with the court’s decision, wholly disapproved of CMS’s policy to implement these unlawful reimbursement cuts at off-campus PBDs. Additionally, the AAMC has requested that CMS restore the higher payment rates for off-campus PBDs and repay hospitals the difference between the amounts received under the unlawful rate and the amount they would have received under the higher payment rates during that periods. 
    • Wage Index Policies. CMS proposed to apply changes to the Medicare wage index finalized in the fiscal year (FY) 2020 Inpatient Prospective Payment System (IPPS) final rule [see Washington Highlights, Aug. 2]. The AAMC requested that CMS explore additional ways to ensure that data for the wage index is accurate and that hospitals at the low end of the wage index are paid appropriately. The AAMC also urged that, if the agency finalizes the proposed changes, CMS extend the length of the transitional 5% cap, limit the policy to four years, and clarify exactly which policies from the FY 2020 IPPS final rule would apply to the OPPS wage index.
    • Prior Authorization Requirements for Hospital Outpatient Department Services. CMS proposed to create prior authorization requirements to control for “unnecessary increases” in utilization for five selected service categories: Blepharoplasty, Botulinum Toxin Injections, Panniculectomy, Rhinoplasty, and Vein Ablation. The AAMC requested that CMS not finalize the prior authorization requirements, asserting that CMS has not adequately demonstrated that the increases in the selected categories are unnecessary, and are instead a result of new clinically valid indications for these services during the time period CMS analyzed to support its proposal. Additionally, the AAMC requested that, if it finalizes the proposal, CMS should guarantee reimbursement if a provider receives “provisional affirmation” for a medically necessary treatment.
    • IPO List Changes. CMS proposed to remove total hip arthroplasty (THA) from the IPO list. The AAMC agreed that THAs can be safely performed on certain patients in the outpatient setting but emphasized that the decision on where the surgery is performed should rest with the treating physician in consultation with the beneficiary. The AAMC also suggested CMS extend the prohibition on Recovery Audit Contractor referrals for inpatient THAs to two years to be consistent with prior rulemaking and assess the policy’s impact on alternative payment models and their target prices.
    • Ambulatory Surgical Center (ASC) List Changes. CMS proposed to add additional services to the ASC covered procedures list. The AAMC requested CMS consider the impact on beneficiaries’ cost-sharing liability as additional services are permitted to be performed in ASCs. 
    • Video Electroencephalogram (EEG) Monitoring Services. CMS proposed to reassign EEG video monitoring to different Ambulatory Payment Classification (APC) codes. The AAMC noted that time should not be the sole distinguishing feature between these codes, as it does not accurately reflect the added costs of complex monitoring associated with these services. CMS should, instead, assign the 2-12 hour monitoring codes to APC 5723 and the 12-26 hour codes to APC 5724 to more accurately reflect the costs that go into complex monitoring at the specialized facilities that most regularly use these codes.
    • Changes to Organ Procurement Organizations (OPOs) Conditions for Coverage (CfCs). CMS proposed to change the conditions for coverage for OPOs to incentivize transplantation of viable organs and sought comments on the validity and reliability of two OPO outcome measures. The AAMC supported CMS’s efforts to maximize availability of organs to patients who desperately need them but emphasized that CMS should ensure changes made to the OPO CfCs do not penalize transplant centers that choose not to transplant organs that may be poor quality.
    • Incorporation of Quality Information with Price Transparency Requirements: CMS issued an RFI on incorporating quality information as part of the agency’s broader price transparency efforts. The AAMC commented that a thoughtful evaluation of options and additional engagement of patients, providers, insurers, and consumer groups is needed to ensure that any future frameworks for cost and quality transparency prioritize patient-centeredness and aid meaningful conversation between patients and their providers.
    • Quality Measure Removals: CMS proposed to remove OP-33 from the Hospital Outpatient Quality Reporting (OQR) Program. The AAMC supported the proposal and requested that CMS consider the removal of additional process measures including OP-18 and OP-8.
    • Future Potential Quality Measures: CMS sought feedback on potentially taking measures from the ASC Quality Reporting Program for future inclusion in the OQR. The AAMC reminded CMS that any future measures should be endorsed by the National Quality Forum, approved by the Measure Applications Partnership, and demonstrated to provide meaningful information for patients and families before they are proposed in the OQR Program.