CMS FY 2019 OPPS/ASC Proposed Rule

Hospitals concerned about more cuts from siteneutral, 340B policies

July 31, 2018

On July 25, the Centers for Medicare and Medicaid Services (CMS) released its 2019 Outpatient Prospective Payment System (OPPS) proposed rule. While the rule contains some standard provisions, such as adjusting rates upwards by 1.25%, WHA is closely analyzing proposed expansion of “site-neutral” policy and 340B provisions that could reduce payments to hospitals.

In its site-neutral recommendations, CMS proposes reducing the payment rate for hospital outpatient clinic visits provided at off-campus provider-based departments (PBDs) to 40% of the OPPS rate. This would even apply to PBDs who were grandfathered in the Bipartisan Budget Act of 2015.

By reducing payments for the most commonly billed service under OPPS, CMS estimates Medicare would save $760 million due to reduced payments from CMS and reduced copays from Medicare beneficiaries. Additionally, CMS would apply this payment rate to new services offered by grandfathered off-campus PBDs that previously did not offer such services.

CMS also proposes changes to the 340B prescription drug discount program. First, it proposes applying last year’s reimbursement cut for disproportionate share (DSH) hospitals (which reduced payments from the Average Sales Price plus 6% to ASP minus 22.5%) to non-grandfathered PBDs – or drugs provided in certain off-campus hospital clinics. CMS would also propose changes to reimbursement related to separately payable biosimilars acquired under 340B and new drugs and biological products.

Despite these two concerning proposals, CMS is continuing its work to remove unnecessary reporting burdens by proposing to remove 10 measures from the Outpatient Quality Reporting Program. The rule also includes new requests for information (RFIs) on price transparency and interoperability or sharing of healthcare data between providers. A fact sheet of the rule can be found here, as well as a full copy of the text here.

Over the next few weeks, WHA staff will analyze the rule in its entirety and submit comments to CMS which are due by September 24, 2018. For further information on the proposed rule, contact Jon Hoelter, WHA Director of Federal and State Relations.

This story originally appeared in the July 31, 2018 edition of WHA Newsletter