CMS Releases 2018 OPPS/ASC and Physician Payment Proposed Rules

July 14, 2017

On July 13, the Centers for Medicare & Medicaid Services (CMS) released 2018 proposed rules regarding the Outpatient Prospective Payment System (OPPS) and the physician fee schedule. The following is a brief synopsis of the key points in the rules.

The OPPS rule proposes to update payment rates by 1.75 percent in calendar year 2018 compared to CY 2017. The rule also would drastically cut Medicare payment for drugs that are acquired under the 340B Drug Pricing Program. Specifically, CMS proposes to pay separately payable, non pass-through drugs (other than vaccines) purchased through the 340B program at the average sales price (ASP) minus 22.5 percent, rather than ASP plus 6 percent.

The OPPS rule also proposes changes to site-neutral policies under Section 603 of the Bipartisan Budget Act of 2015. Section 603 requires that, with the exception of dedicated emergency department services, services furnished in off-campus provider-based departments that began billing under the OPPS on or after November 2, 2015 no longer be paid under the OPPS, but under another applicable Part B payment systems. Under the physician fee schedule proposed rule, those services would now be paid at 25 percent rather than 50 percent of the OPPS rate for non-excepted services in 2018.

The OPPS proposed rule would also reinstate for CYs 2018 and 2019 the moratorium on enforcement of the direct supervision policy for outpatient therapeutic services for critical access hospitals and small rural hospitals with 100 or fewer beds. In addition, CMS proposes to delay implementation of the outpatient and ASC CAHPS survey-based measures in the Outpatient Quality Reporting (OQR) program until further notice. The rule also would remove six quality measures from the OQR. CMS does not propose relief from the Stage 3 reporting requirements that begin on January 1, 2018.

The rule on the physician fee schedule for calendar year 2018 proposes an estimated 0.31 percent increase in physician payment rates for 2018 compared to 2017, after applying a 0.5 percent payment increase required by the Medicare Access and CHIP Reauthorization Act of 2015 and a misvalued code adjustment required under the Achieving a Better Life Experience Act of 2014. CMS proposes to pay for new telehealth services, including psychotherapy for crisis, health risk assessments and care planning for chronic care management. In addition, the rule would delay until January 1, 2019, the appropriate use criteria program for advanced diagnostic imaging services; and establish payment to rural health clinics and federally qualified health clinics for regular and complex chronic care management services, general behavioral health integration services and psychiatric collaborative care model services.

While data submission for the CY 2018 Physician Quality Reporting System has passed, CMS proposes to retroactively lower the number of required measures from nine to six to more closely align the program with the new Merit-based Incentive Payment System that will affect payment starting in CY 2019. CMS also proposes to lower the maximum amount of payment at risk under the CY 2018 value modifier program from 4.0 percent to 1.0 percent for individual clinicians and groups of under 10 clinicians, and to 2.0 percent for groups of 10 or more clinicians.

Both proposed rules have comment due dates of September 11. WHA will put out a more detailed summary and will comment on the rules, concentrating on the problematic areas regarding the 340B program and the site neutral payment changes.

This story originally appeared in the July 14, 2017 edition of WHA Newsletter