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2019 outpatient prospective payment system final rule key points

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The 2019 Hospital Outpatient Prospective Payment System (OPPS) Final Rule has been issued and changes are on the way that can affect your organization’s Medicare reimbursement.

As part of our commitment to help protect and enhance your Medicare revenue, we’ve developed this expert analysis of the FY 2019 OPPS Final Rule to quickly give you insight into the most important changes.

BESLER remains your trusted advisor and we look forward to helping you identify areas of revenue opportunity for your facility.

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2019 outpatient prospective payment system final rule key points

  1. 1. 2019 OPPS Final Rule Key Points
  2. 2. The 2019 Hospital Outpatient Prospective Payment System (OPPS) Final Rule has been issued and changes are on the way that can affect your organization’s Medicare reimbursement. As part of our commitment to help protect and enhance your Medicare revenue, we’ve developed this expert analysis of the FY 2019 OPPS Final Rule to quickly give you insight into the most important changes. BESLER remains your trusted advisor and we look forward to helping you identify areas of revenue opportunity for your facility. Jonathan Besler President & CEO
  3. 3. The Medicare Hospital Outpatient Prospective Payment System (IPPS) rates are required by law to be updated annually. This report contains key changes to the FY2019 OPPS Final Rule. You can access the final rule on the Federal Register: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24243.pdf
  4. 4. • Key themes • Payment rates • Comprehensive APCs • Inpatient only list • Method to control unnecessary increases in volume of outpatient services • Expansion of clinical families of services at excepted off- campus provider based departments (PBDs) of a hospital • Application of 340B drug payment policy to nonexcepted off-campus provider-based departments of a hospital • Device-intensive procedure criteria • Hospitals with protection • Adjustments • Ambulatory Surgical Center (ASC) payment update • Changes to the list of ASC covered surgical procedures • Device-intensive procedure criteria • Ambulatory Surgical Center Quality Reporting (ASCQR) Program • E&M flat rate reimbursement delayed • Claims submitted with Modifier 25 proposed changes Contents • Payment policy for biosimilar biological products without pass-through status that are acquired under 340B
  5. 5. Key themes
  6. 6. Price Transparency- Not clarified in the OPPS Final Rule • All hospitals including CAHs must post prices. • Format instructions from CMS are unclear. • Includes all standard charges for items and services provided by the hospital.
  7. 7. Telemedicine • Medicare payment policies are designed to promote access to virtual care. • Includes increased telehealth services and easier access for seniors for the monitoring of chronic conditions. • Telemedicine needs to adhere to a few core principles of quality for payment in both urban and rural areas.
  8. 8. Expansion of eligible clinicians to include physical therapists, occupational therapists, clinical social workers and clinical psychologists. Opt-in for low threshold clinicians. MIPS Ending 26 ineffective measures after hearing from stakeholders Adding 8 quality measures including 4 based on patient outcome reporting X +
  9. 9. Reducing physician administrative burden and burnout • The rule streamlines documentation requirements. • Reduces paperwork burdens that interfere with a meaningful patient-physician relationship. • Intended so providers can spend more time with patients and quickly locate relevant information in medical records.
  10. 10. OPPS updates
  11. 11. For CY 2019, CMS is increasing the payment rates under the OPPS by an outpatient department (OPD) fee schedule increase factor of 1.35 percent. This increase factor is based on the final hospital inpatient market basket percentage increase of 2.9 percent for inpatient services paid under the hospital inpatient prospective payment system (IPPS), minus the multifactor productivity (MFP) adjustment of 0.8 percentage point, and minus a 0.75 percentage point adjustment required by the Affordable Care Act. Payment rates
  12. 12. For CY 2019, CMS is creating three new comprehensive APCs (C-APCs) These new C-APCs include ears, nose, and throat (ENT) and vascular procedures The total number of C-APCs increases to 65 Comprehensive APCs
  13. 13. Inpatient only list Removing 4 procedures from the list Adding 1 procedure to the list X +
  14. 14. Method to control unnecessary increases in volume of outpatient services To the extent that similar services are safely provided in more than one setting, it is not prudent for the OPPS to pay more for such services because that leads to an unnecessary increase in the number of those services provided in the OPPS setting. Capping the OPPS payment at the Physician Fee Schedule (PFS)-equivalent rate is an effective method to control the volume of the unnecessary increases in certain services because the payment differential that is driving the site-of-service decision will be removed.
  15. 15. Expansion of clinical families of services at excepted off-campus provider based departments (PBDs) of a hospital Proposed that if an excepted off-campus PBD furnished items and services from a clinical family of services from which it did not furnish items and services (and subsequently bill for those items and services) during a baseline period, services from the new clinical family of services would not be covered OPD services. Instead, services in the new clinical family of services would be paid under the PFS. Not finalized
  16. 16. Application of 340B drug payment policy to nonexcepted off-campus provider-based departments of a hospital CMS will pay the average sales price (ASP) minus 22.5 percent under the PFS for separately payable 340B-acquired drugs furnished by nonexcepted, off-campus provider-based departments (PBDs) of a hospital. This is consistent with the payment methodology adopted in CY 2018 for 340B-acquired drugs furnished in hospital departments paid under the OPPS.
  17. 17. Payment policy for biosimilar biological products without pass-through status that are acquired under the 340B program For CY 2019, CMS is making payments for nonpass-through biosimilars acquired under the 340B program at ASP minus 22.5 percent of the biosimilar’s own ASP rather than ASP minus 22.5 percent of the reference product’s ASP.
  18. 18. For CY 2019, CMS is modifying the device- intensive criteria to allow procedures that involve single-use devices, regardless of whether or not they remain in the body after the conclusion of the procedure, to qualify as device-intensive procedures. CMS also are allowing procedures with a device offset percentage of greater than thirty percent to qualify as device-intensive procedures. Device-intensive procedure criteria
  19. 19. Hospitals with protection CAHs continue to receive cost reimbursement with the payment level set at 1% above cost or 101% of cost (before sequestration). Children’s Hospitals and cancer centers have a permanent hold harmless protection. Non-enforcement of direct supervision, which had previously been in place for outpatient therapeutic services remains in place for CY 2019 for CAHs and small rural hospitals with <100 beds.
  20. 20. Adjustments Cancer Hospitals - additional payments to cancer hospitals so that the cancer hospital’s payment-to-cost ratio (PCR) after the additional payments is equal to the weighted average PCR for the other OPPS hospitals using the most recently submitted or settled cost report data. Rural Adjustment - 7.1 percent adjustment to OPPS payments for certain rural SCHs, including essential access community hospitals (EACHs). This will continue for future years in the absence of data to suggest a different percentage adjustment should apply.
  21. 21. Ambulatory Surgical Center (ASC) payment update Using the hospital market basket methodology, for CY 2019, CMS is increasing payment rates under the ASC payment system by 2.1 percent for ASCs that meet the quality reporting requirements under the ASCQR Program. This increase is based on a hospital market basket percentage increase of 2.9 percent minus a MFP adjustment required by the Affordable Care Act of 0.8 percentage point.
  22. 22. Changes to the list of ASC covered surgical procedures Adding 12 cardiac catheterization procedures Includes an additional 5 related cardiac procedures to the ASC covered procedures list
  23. 23. OP-5: Median Time to ECG OP-9: Mammography Follow-up Rates; OP-11: Thorax CT Use of Contrast Material; OP-12: The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into Their Qualified/Certified EHR System as Discrete Searchable Data; OP-14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT; OP-17: Tracking Clinical Results between Visits; OP-30: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use. CMS did not finalize proposals to remove the OP-29 or OP-31 measures. Device-intensive procedure criteria
  24. 24. Ambulatory Surgical Center Quality Reporting (ASCQR) Program • Extending the reporting period for the ASC-12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy measure to 3 years. • Removing the ASC-8: Influenza Vaccination Coverage Among Healthcare Personnel measure. • Removing the ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use measure. • Not finalized: Proposals to remove the following measures: ASC-9: Endoscopy/Polyp Surveillance Follow-up Interval for Normal Colonoscopy in Average Risk Patients and ASC-11: Cataracts - Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery. • Not finalizing our proposals to remove the following measures: ASC-1: Patient Burn; ASC-2: Patient Fall; ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; and ASC-4: All-Cause Hospital Transfer/Admission. • CMS is retaining these measures in the ASCQR Program and suspending data collection for them until further action in rulemaking with the goal of revising the measures.
  25. 25. The flat-rate reimbursement and the documentation relaxation proposed by the Centers for Medicare & Medicaid Services (CMS) did not pass for implementation in 2019. Approved but delayed until 2021 to allow more time for reconciliation with stakeholders. E&M flat rate reimbursement delayed
  26. 26. Claims submitted with Modifier 25 proposed changes CMS is comparing an E&M with a procedure to a surgical encounter in which multiple payment reductions are applicable. CMS feels that there are “efficiencies” associated with an E&M encounter and procedure on the same visit that the multiple payment rule should be applied to these instances. Excluded from the OPPS Final Rule
  27. 27. BESLER combines best-in-class healthcare finance expertise with proprietary technology to help hospitals recover more revenue. Our reimbursement and recovery solutions have delivered more than $2 billion of additional revenue to hundreds of hospitals across the United States. We serve as advocates for hospitals, so that they, in turn, can better advance the health and well-being of their patients. Transfer DRG Revenue Recovery IME Revenue Recovery Reimbursement Revenue Integrity 3 Independence Way, Suite 201 Princeton, New Jersey 08540 1.877.4BESLER www.besler.com

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