Updates to CMS Outpatient Rules
October 1, 2022 3 minutes read
By Jeni Miller
In July, CMS issued proposed rules that could raise Medicare Outpatient Prospective Payment System (OPPS) rates in 2023.1 While the document is more than 800 pages, here are three important items that may be of interest to hospital case managers, especially those serving in ambulatory surgical centers (ASCs).
The proposal will affect about 5,500 ASCs and 3,400 hospitals.2
Rural Emergency Hospitals
The first proposed rule is primarily designed to help enhance access to care in rural settings. It creates a new type of provider, called Rural Emergency Hospitals (REHs), which takes effect Jan. 1, 2023.
According to CMS, a REH is a facility that converts “from either a critical access hospital or a rural hospital (or one treated as such under section 1886(d)(8)(E) of the Social Security Act) with less than 50 beds, and that do not provide acute care inpatient services with the exception of posthospital extended care services furnished in a unit of the facility that is a distinct part licensed as a skilled nursing facility.”
CMS also noted “the policies in these proposed rules will allow rural hospitals to seek this new designation and provide continued access to emergency services, observation care, and additional medical and outpatient services.”
The rules describe several proposed payment changes to REHs and will include a monthly facility payment, a payment for providing “services at a rate that is equal to the OPPS payment rate for the equivalent covered outpatient department service increased by 5%.” CMS also intends to consider REH services all covered outpatient department services.
These changes could help improve finances for those living in rural areas as well as the hospitals that serve these populations. CMS also described “a growing concern that closures of rural hospitals and critical access hospitals (CAHs) are leading to a lack of services for people living in rural areas.”2
OPPS Rate Increase
CMS proposed increasing OPPS rates by 2.7% in 2023 over 2022 for hospitals that meet their quality reporting requirements. “This proposed increase is based on a hospital market basket percentage increase of 3.1% reduced by a productivity adjustment of 0.4 percentage point,” the agency explained.
Inpatient-Only List
A third proposed rule includes removing 10 services from the Inpatient Only (IPO) list for 2023. “Since the beginning of the OPPS, the IPO has defined the list of services that, due to their medical complexity, Medicare will only pay for when performed in the inpatient setting,” according to the proposed rule. It was not immediately clear which 10 services will be removed from the IPO list. The agency also is seeking to add a lymph node biopsy or excision procedure to the ASC Covered Procedures List.
CMS also addressed opioid use disorder and payments under the OPPS for opioids vs. evidence-based non-opioid alternatives for pain management. They seek to ensure there are no financial incentives that would encourage the use of opioids over other medications.
“In addition to the mental health crisis exacerbated by the COVID-19 pandemic, the United States is currently in the midst of an ongoing opioid [public health emergency], which was first declared on October 26, 2017, by former Acting Secretary Eric D. Hargan, and most recently renewed by Secretary Xavier Becerra on April 4, 2022, and is facing an overdose crisis as a result of rising polysubstance use, such as the co-use of opioids and psychostimulants (for example, methamphetamine, cocaine),” according to CMS.
CMS accepted public comment on the proposal until Sept. 13, 2022.
REFERENCES
- Centers for Medicare & Medicaid Services. Medicare program: Hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs; organ acquisition; rural emergency hospitals: Payment policies, Conditions of Participation, provider enrollment, physician self-referral; new service category for hospital outpatient department prior authorization process; overall hospital quality star rating. Federal Register. July 26, 2022.
- Centers for Medicare & Medicaid Services. CY 2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed rule (CMS 1772-P). July 15, 2022.
In July, CMS issued proposed rules that could raise Medicare Outpatient Prospective Payment System rates in 2023.
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