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Medicare Outpatient Expenditures Estimated to Grow $6.5B

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The calendar year 2023 Outpatient Prospective Payment System (OPPS) final rule, issued Nov. 1, 2022, by the Centers for Medicare and Medicaid Services estimates that Medicare expenditures under OPPS will increase by $6.5 billion, relative to estimated current year payments, based on changes in the final rule. Key provisions are:  

  • Payment Update: CMS updated OPPS and ambulatory surgery center (ASC) payment rates for entities that meet quality reporting requirements by 3.8% (compared to 2.7% as proposed). The final payment update reflects a market basket increase of 4.1%, reduced by 0.3% productivity adjustment). However, after the budget neutrality adjustments are applied, the conversion factor for 2023 increases by 1.67% compared to 2022 ($85.585, CY 2023 vs. $ 84.177, CY 2022). 
  • Payment for Separately Payable Drugs Acquired Under the 340B Program: CMS finalized a payment rate of average sales price plus 6% for drugs and biologicals acquired through the 340B Program. CMS is implementing a –3.09% budget neutrality reduction to the payment rates for non-drug services. In the rule, CMS states it will address the remedy for 340B drug payments from 2018-2022 in future rulemaking prior to the CY 2024 OPPS/ASC proposed rule. 
  • Inpatient Only List: In the final rule, CMS removed 11 services from the inpatient only list. 
  • ASC Covered Procedures List: CMS finalized its proposal to add four procedures to the ASC covered procedure list. 
  • Behavioral Telehealth Services Furnished by Hospital Staff to Patients in Their Homes: CMS finalized its proposal to consider behavioral health services delivered remotely by staff of hospital outpatient departments, including critical access hospitals, using telecommunications technology to beneficiaries in their homes as covered services and paid for under the OPPS. CMS also finalized that audio-only interactive telecommunications systems may be used and considered covered services in certain circumstances.  
  • IPPS/OPPS Payment Adjustment for Domestically Produced N95s: CMS finalized proposed payment adjustments for the Inpatient Prospective Payment System (IPPS) and OPPS that offset the additional marginal costs incurred by purchasing domestically produced N95 masks. These payments will be provided biweekly as interim lump-sum payments to the hospital that would be reconciled at cost report settlement. The rule outlines the information that will be collected in the Medicare cost report.   
  • Expanding Prior Authorization: CMS adds facet joint injections and nerve destruction to the list of services requiring prior authorization. This requirement will be effective July 1, 2023. 
  • Sole Community Hospital (SCH) Exemption to Site Neutral Clinic Visit Policy: The final rule exempts rural SCHs from the site neutral payment policy for clinic visits furnished in excepted off-campus provider-based departments (PBDs). Services provided in SCH excepted PBDs will be paid at the full OPPS rate in CY 2023. 
  • Organs Procured for Research/RFI on Organ Procurement: CMS finalized a method of accounting for research organs that will improve payment accuracy and lower the costs to procure and provide research organs to the research community. The rule also includes provisions that address financial barriers to organ donation after cardiac death. 
  • Hospital Outpatient Quality Reporting (OQR) Program and Hospital Star Ratings: CMS did not finalize any new measures for the hospital OQR program but did revise certain program requirements. CMS also provided clarifications for the Overall Hospital Quality Star Rating program. 
  • Rural Emergency Hospital (REH) Payments: CMS finalized its proposal that all covered outpatient department services would be covered under the OPPS as REH services. These services provided by REHs will receive an additional 5% payment. REHs will also receive a monthly facility payment starting in CY 2023 that will increase in subsequent years by the hospital market basket percentage increase. 

REHs may provide outpatient services that are not paid under the OPPS as well as post-hospital extended care services furnished in a unit of the facility that is a distinct part of the facility licensed as a skilled nursing facility. However, these services will not be considered REH services. They will be paid under the applicable fee schedule and not eligible for the additional 5% payment increase that CMS applies to REH services. 

The OPPS final rule also includes the conditions of participation (CoP) for REHs. In most cases, these standards align with the current critical access hospital CoP. 

CHA is reviewing the rule and will make a detailed summary available to members via CHA news shortly.  A CMS fact sheet is available at its website.