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  • Washington Highlights

    CMS Releases CY 2020 OPPS Proposed Rule

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

    The Centers for Medicare and Medicaid Services (CMS) July 29 released the Outpatient Prospective Payment System (OPPS) proposed rule containing changes to Medicare payment policies and OPPS rates for calendar year (CY) 2020.

    Key proposals in the proposed rule are as follows:

    Outpatient Payment Update: CMS is proposing an increase of approximately 2.7% to OPPS payment rates based on a market basket increase of 3.2%, reduced by 0.5 multifactor productivity adjustment.

    Site-Neutral Implementation: CMS proposes to implement the second year of reductions in payment for clinic visits (HCPCS code G0463) furnished at off-campus provider-based departments (PBDs). The policy, which was introduced in last year’s CY 2019 OPPS final rule [see Washington Highlights, Nov. 9, 2018], will reduce reimbursement to 40% of the OPPS rate for clinic visits, completing its phase-in initiated in CY 2019. The policy is not implemented in a budget neutral manner.

    Hospital Price Transparency: CMS is proposing to require that hospitals make public their standard charges — both gross and payer-specific negotiated charges — for all items and services online in a machine-readable format. The proposal defines “hospitals” as all Medicare-enrolled institutions that are licensed as hospitals (or approved as meeting licensing requirements) as well any non-Medicare enrolled institutions that are licensed as a hospital (or approved as meeting licensing requirements).

    Additionally, CMS would require hospitals to make public payer-specific negotiated charges for at least 300 hospital-provided items and services that are “shoppable” and displayed in a consumer-friendly manner. CMS defines a “shoppable service” as a service that can be scheduled by a health care consumer in advance. CMS would select 70 services and the individual hospital would select the remaining 230 services to be included. Under the proposal, hospitals may receive civil monetary penalties (CMPs) for noncompliance.

    The AAMC issued a July 29 joint statement with four other hospital urging CMS to not finalize this provision. The letter notes, “Disclosing the negotiated rate between insurers and hospitals will not help patients made decisions about their care. Instead, this disclosure could harm patients by reducing patient access to care.”

    Wage Index: CMS proposes to apply, if finalized, the fiscal year (FY) 2020 Inpatient Prospective Payment System (IPPS) postreclassified wage index to OPPS to determine wage adjustments for the OPPS payment rate and the copayment standardized amount. The IPPS proposals [see Washington Highlights, April 26], if finalized, would increase the wage index for low wage index hospitals (wage index value below the 25th percentile) and decrease the wage index for high wage index hospitals (wage index value above the 75th percentile) for at least the next four years, and would remove reclassified hospitals from the calculation of the rural floor. Decreases from these wage index policies would be capped at 5% for CY 2020.

    340B Drug Pricing Program: CMS seeks to continue paying for drugs acquired through the 340B program at average sales price (ASP) minus 22.5% when furnished at nonexempt, off-campus PBDs. In addition to this proposal, CMS is soliciting comments on alternative payments for 340B-acquired drugs, including comments on an ASP plus 3% proposal. CMS is also soliciting comments on potential remedies for CY 2018 and 2019 payments in the event of an adverse ruling in the ongoing 340B litigation against the agency.

    Comprehensive Ambulatory Payment Classifications (C-APCs): CMS proposes to create two new C-APCs: C-APC 5182 (Level 2 Vascular Procedures) and C-APC 5461 (Level 1 Neurostimulator Related Procedures). This proposal would increase the total number of C-APCs to 67.

    Inpatient Only (IPO) List: CMS proposes to remove Total Hip Arthroplasty from the IPO list, which would make the procedure eligible for Medicare payment in both the inpatient and outpatient settings.

    Changes to the List of Ambulatory Surgery Center (ASC) Covered Surgical Procedures: CMS proposes to add eight procedures to the ASC list of covered surgical procedures, including Total Knee Arthroplasty, Knee Mosaicplasty, and six coronary intervention procedures.

    Innovative Technologies: CMS proposes that innovative technologies and treatments that meet the Food and Drug Administration’s Breakthrough Device designation would be eligible for device pass-through payment status and would not be subject to the agency’s “substantial clinical improvement” criterion.

    Prior Authorization: CMS proposes to implement a prior authorization requirement for Blepharoplasty, Botulinum Toxin Injections, Panniculectomy, Rhinoplasty, and Vein Ablation.

    Quality Provisions: CMS proposes to remove one web-based measure for the CY 2022 Program Year from the Hospital Outpatient Quality Reporting (OQR) Program (External Beam Radiotherapy for Bone Metastases [OP-33]). CMS is also soliciting public comments on potentially adding four patient safety measures that are used in the Ambulatory Surgery Center (ASC) Quality Reporting program to the Hospital OQR program in future rulemaking: ASC 1-4 (including ASC-1: Patient Fall; ASC-2: Patient Burn; ASC-3: Wrong Site, Wrong Side, Wrong Procedure, Wrong Implant; and ASC-4: All-Cause Hospital Transfers/Admissions).

    The AAMC will submit comments on the proposed rule, which are due by Sept. 27.