The Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2021 hospital outpatient prospective payment system (OPPS) final rule with comment period (fact sheet) addressing payments to hospital outpatient departments and ambulatory surgery centers (ASCs). Addenda referred to in the final rule for the OPPS system and the ASC payment system are available here and here, respectively.
- What it is. CMS’ wide-ranging final rule affects payments to approximately 3,665 facilities paid under the OPPS, including hospital outpatient departments (OPDs) and ASCs, beginning on Jan. 1, 2021.
- Why it’s important for you. In keeping with the Trump Administration’s directives to lower out-of-pocket costs by enacting site neutral payment policies across inpatient, outpatient, and ambulatory settings, the final rule expands the number of reimbursable procedures in the ASC setting and implements a phased elimination of restrictions on procedures that are currently deemed inpatient-only. Though CMS had proposed to further reduce payment for separately payable drugs or biologicals acquired by participating hospitals in the 340B Program, the agency ultimately chose not to apply additional cuts and instead finalizes a rate equal with its current policy of paying Average Sales Price (ASP) minus 22.5 percent. Among other provisions, CMS finalizes several changes to streamline the Overall Hospital Star Rating system methodology; allows physician-owned hospitals with high proportions of Medicaid patients to more easily and frequently expand their facilities; announces a delay in the initiation of the Radiation Oncology (RO) payment model; and introduces new reporting requirements for hospitals related to the impact of acute respiratory illnesses, such as COVID-19 and seasonal influenza, on hospital resources.
- Potential next steps. Upon formal publication of the final rule in the Federal Register, a 30-day public comment period will apply to the following provisions: the payment classifications assigned to the interim Ambulatory Payment Classification (APC) assignments; and/or status indicators of new or replacement Level II HCPCS codes in this final rule (see p. 196). Additionally, a 60-day comment period will apply to the new provisions addressing reporting requirements for hospitals and CAHs to report acute respiratory illness during the PHE for COVID-19, and to the delay of the Radiation Oncology Model.
Highlights of the OPPS final rule are summarized in the attached document.