CMS Proposes Sweeping Changes to Site Payments, Quality Reporting

July 30th, 2018

By Jill Drachenberg, Editor, Relias Media

Site-neutral care reimbursement, changes to quality reporting, and new ways to combat the opioid crisis are among a slew of possible new rules in the Centers for Medicare & Medicaid Services (CMS) 2019 Outpatient Prospective Payment System (OPPS).

In a fact sheet on the OPPS, CMS explains that adjusting payments for clinic visits to hospital outpatient departments according to the Physician Fee Schedule (PFS) rates will lower costs for both Medicare patients and CMS. Outpatient department clinic visits currently are reimbursed at a higher rate than equivalent visits to nonhospital physician offices. These are the most commonly billed OPPS service.

“This proposed change would result in lower copayments for beneficiaries and savings for the Medicare program which are estimated to be $760 million for 2019,” according to the fact sheet. “For an individual Medicare beneficiary, current Medicare payment for the clinic visit is approximately $116 with $23 being the average beneficiary copayment.” Under the OPPS, beneficiary copays would be reduced to $9.

CMS also is proposing a rule called Meaningful Measures/Patients Over Paperwork, which will reduce reporting requirements for quality measures. Fifteen measures under consideration for removal were chosen after what CMS describes as a “careful and holistic review” of the current requirements. Measures are targeted for removal “if they are duplicative, [if] they are ‘topped out’ (meaning that the overwhelming majority of providers are performing highly on them), or if their costs are greater than benefits in reporting.”

Examples of topped-out measures include patient burn; patient fall; and wrong site, wrong side, wrong procedure, or wrong implant. Influenza vaccine coverage among healthcare workers is targeted for removal from the required reporting list because the costs outweigh the benefits of reporting.

OPPS also is proposing the following:

• updating ambulatory surgery center reimbursement rates and expanding the Covered Procedures List;
• removing three pain management questions from the Hospital Consumer Assessment of Healthcare Providers and Systems patient experience survey to discourage overprescribing of opioids;
• seeking public comment on ways to reduce Medicare Part B drug costs through Competitive Acquisition Program.

The complete OPPS proposed rule is available on the Federal Register, and public comment is open through Sept. 24.