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CMS Issues CY 2022 OPPS Final Rule, Increases Price Transparency Penalties

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On Nov. 2, the Centers for Medicare & Medicaid Services (CMS) finalized Medicare payment rates for hospital outpatient and ambulatory surgical center (ASC) services. CMS estimates that Medicare expenditures under the outpatient prospective payment system (OPPS) will increase by $1.3 billion based on changes in the final rule.

Key provisions of the rule are summarized below. 

  • Payment Update: The rule updates OPPS payment rates for hospitals that meet quality reporting requirements by a net 2% (decreased from 2.3% in the proposed rule). The update is based on the projected hospital market basket increase of 2.7% reduced by 0.7 percentage points for the productivity adjustment. CMS finalizes an OPPS conversion factor of $84.177 (increased from increased from $82.797 in CY 2021) for hospitals that satisfy the quality reporting requirements. 
  • Price Transparency: Civil monetary penalties (CMPs) associated with the hospital price transparency requirement are increased. Beginning Jan. 1, 2022, CMS sets a minimum CMP of $300 per day for hospitals with 30 or fewer beds, and a penalty of $10 per bed per day for hospitals with a bed count greater than 30. The penalty is capped at a maximum daily dollar amount of $5,500. For a full calendar year of noncompliance, the minimum total full year penalty amount would be $109,500 per hospital, and the maximum would be $2,007,500. The final rule also prohibits certain activities that block access to the machine-readable file by requiring that these files be accessible to automated searches and direct downloads. 
  • OPPS Payment for 340B Acquired Drugs: CMS finalizes its proposal to continue the payment rate of average sales price minus 22.5% for certain separately payable drugs acquired through the 340B Program. Rural sole community hospitals, children’s hospitals, and PPS-exempt cancer hospitals are excepted from this policy.  
  • Inpatient-Only (IPO) List: CMS halts the elimination of the IPO list. The final rule also adds back to the IPO list the services removed in 2021, except for CPT codes 22630 (lumbar spine fusion), 23472 (reconstruct shoulder joint), 27702 (reconstruct ankle joint). Because CMS is halting the elimination of the IPO list, the agency is also finalizing its proposal to revise the site of service review exemption for procedures removed on or after Jan. 1, 2021. Procedures removed from the IPO list will now be exempt from site-of- service reviews for a two-year period, instead of indefinitely as was finalized in the calendar year (CY) 2021 rule. 
  • ASC Rate Update: CMS updates the ASC payment rates for CY 2022 by 2% for ASCs that meet applicable quality reporting requirements. For ASCs that meet the quality reporting requirements, the final CY 2022 conversion factor is $49.916 (increased from $48.952 in CY 2021). 
  • ASC Covered Procedures List: For CY 2022, CMS reinstates the criteria for adding procedures to the ASC-covered procedures list that was in place in CY 2020. As a result, the final rule removes 255 procedures from the list. Of the 258 procedures proposed for removal from the ASC-covered procedures list, the final rule retains three. CMS also finalizes the adoption of a process, beginning in March 2022, to allow an external party to nominate a surgical procedure to be added to the ASC-covered procedures list. 
  • Radiation Oncology (RO) Model: The RO Model will begin on Jan. 1, 2022, with a five-year model performance period, ending Dec. 31, 2026. Among other changes, the rule finalizes a reduction in the discount factors for the professional and technical component, removes liver cancer from the model, and removes brachytherapy from the list of modalities included in the model.  
  • Hospital Outpatient Quality Reporting (OQR) Program: CMS finalizes proposals to adopt three new measures, including the COVID-19 Vaccination of Health Care Personnel (NQF #0431), make the reporting of two voluntary or suspended measures mandatory, remove two measures, and update the validation policies of the Hospital OQR Program to reduce provider burden and improve processes. 
  • Ambulatory Surgical Center Quality Reporting Program: CMS finalizes proposals to adopt one new measure, the COVID-19 Vaccination of Health Care Personnel (NQF #0431), and make the reporting of six voluntary or suspended measures mandatory.