December 18, 2019
Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments: Updated
On background, the American Hospital Association challenged CMS’s use of its authority under Section 1833(t)(2)(F) of the Medicare statute to pay for certain outpatient clinic visit services provided at excepted off-campus Provider-Based Departments (PBDs) at the same rate that CMS uses to pay non-excepted off-campus PBDs for those services under the separate Physician Fee Schedule (PFS) as finalized in the Final Rule, Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting, 83 Fed. Reg. 58,818 (Nov. 21, 2018) (Rule).
The United States District Court for the District of Columbia issued instructions for CMS to immediately cease paying the reduced amount for clinic visits furnished at excepted off-campus PBDs for CY 2019 implemented in the Rule.
CMS installed a revised Hospital Outpatient Prospective Payment System (OPPS) Pricer to update the rates being applied to claim lines. The revised Pricer went into production on November 4, 2019, and applies to claims with a line item date of service of January 1, 2019, and after. Starting January 1, 2020, and over the next few months, the Medicare Administrative Contactors will automatically reprocess 2019 claims paid at the reduced rate; no provider action needed.
In the 2020 OPPS final rule, CMS is completing the two-year phase-in to apply the full amount of the reduction in payment for clinic visits furnished in off-campus provider-based departments to the same amount paid under the PFS. This policy was adopted as a method to control unnecessary increases in the volume of clinic visit services furnished in off-campus provider-based departments paid under the OPPS and will help reduce out-of-pocket costs for Medicare beneficiaries. From the final 2020 OPPS rule: “We acknowledge that the district court vacated the volume control policy for CY 2019 and we are working to ensure affected 2019 claims for clinic visits are paid consistent with the court’s order. We do not believe it is appropriate at this time to make a change to the second year of the two year phase-in of the clinic visit policy.” (84 FR 61145) In the final rule, CMS stated that the government was evaluating its appeal rights and considering whether to appeal from the court’s final judgment. On December 12, 2019, the Department filed its notices of appeal in the three consolidated cases in the United States District Court for the District of Columbia Circuit.
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