Seema Verma
In the proposed update to the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for 2019, CMS is proposing to apply a physician fee schedule–equivalent for the clinic visit service when provided at an off-campus, provider-based department that is paid under OPPS.
According to CMS, the average current clinical visit paid by CMS is $116 with $23 being the average copay by the patient. If the proposal is finalized, the payment would drop to about $46 with an average patient copay of $9.
“This is intended to address concerns about recent consolidations in the market that reduce competition,” CMS Administrator Seema Verma said during a July 25 press conference.
The American Hospital Association already is pushing back on this proposal.
“With today’s proposed rule, CMS has once again showed a lack of understanding about the reality in which hospitals and health systems operate daily to serve the needs of their communities,” AHA Executive Vice President Tom Nickels said in a statement. “In 2015, Congress clearly intended to provide current off-campus hospital clinics with the existing outpatient payment rate in recognition of the critical role they play in their communities. But CMS’s proposal runs counter to this and will instead impede access to care for the most vulnerable patients.”
The OPPS/ASC update also includes proposals to expand the list of covered surgical procedures that can be performed in an ASC, a move that Ms. Verma said would “provide patients with more choices and options for lower-priced care.”
“For CY 2019, CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the [covered procedure list] and is proposing to add certain cardiovascular codes to the ASC [covered procedure list] as a result,” the CMS fact sheet notes.
Another change proposed by CMS relates to how ASC reimbursement rates are updated. They have been based on the consumer price index-urban, which has resulted in a decline in ASC payments relative to hospitals for the same service. For 2019-2023, CMS proposes to use the hospital market basket instead, which will help promote site neutrality between hospitals and ASCs. The AGA applauds this proposal, and has been working for it with the ACG and ASGE for nearly a decade.
In addition, the OPPS is seeking feedback on a number of topics.
One is related to price transparency. The agency is asking “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other charges are needed to empower patients,” according to the fact sheet.
Finally, the agency is seeking more information on solutions to better promote interoperability.
