On October 30, 2015, CMS issued its final rule with comment period (Final Rule) for the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for calendar year 2016, as well as updates to the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. The Final Rule also finalized certain policies relating to the hospital inpatient prospective payment system (IPPS), including changes to the two-midnight rule.
CMS estimates that based on the Final Rule, total payments for CY 2016 to the estimated 4,000 facilities paid under the OPPS will decrease by a projected $133 million (0.4 percent) compared to CY 2015. This impact is greater than the proposed rule’s estimated $43 million (0.2 percent) decrease in total OPPS payments. Additionally, although the proposed rule estimated a payment increase to ASCs of 1.1 percent, under the Final Rule, CMS estimates that total payments to ASCs for CY 2016 will be approximately $4.221 billion, an increase of only 0.3 percent, or approximately $128 million, as compared to estimated CY 2015 Medicare payments.
In the Final Rule, CMS has finalized a number of changes for CY 2016, including the following changes to OPPS and the ASC payment system:
Under the Final Rule, CMS has also modified its prior “exceptions” policy under the two-midnight benchmark, which previously was limited to cases involving services designated by CMS as inpatient-only and those other exceptions published on the CMS website or in other sub-regulatory guidance. CMS will now allow exceptions to the two-midnight benchmark to be determined on a case-by-case basis by the beneficiary’s responsible physician, subject to medical review. CMS is careful to note that it expects that stays less than 24 hours would rarely fall into an exception.
The Final Rule also finalized certain proposed changes from the FY 2015 IPPS Proposed Rule to the Medicare regulations governing provider administrative appeals and judicial review relating to appropriate claims in provider cost reports. Specifically, CMS has finalized revisions to the cost reporting rules requiring providers to include an appropriate claim for a specific item on their cost reports—either by affirmatively claiming reimbursement or expressly self-disallowing the cost by filing a cost report item under protest—in order to be eligible to potentially receive Medicare reimbursement and/or to be eligible to appeal their reimbursement (or lack thereof) to the Provider Reimbursement Review Board. CMS has eliminated the duplicative requirement to do the same in order to meet the “dissatisfaction” requirement for Board jurisdiction. CMS has also specified procedures for Board review of whether a provider’s cost report meets this substantive reimbursement requirement of an appropriate cost report claim for a specific item.
Any comments on the payment classifications assigned to HCPCS codes identified in Addenda B, AA, and BB with the “NI” comment indicator and on other areas indicated in the Final Rule must be received no later than 5 p.m. EST on December 29, 2015.
The CMS Fact Sheet on the Final Rule is available here. An additional Fact Sheet on the Two-Midnight Rule is available here. The Final Rule is scheduled to be published in the Federal Register on November 13, 2015. Our Health Headlines article summarizing the proposed rule is available below.
Reporter, Christina A. Gonzalez, Houston, +1 713 276 7340, firstname.lastname@example.org