Medicare regulators are updating hospital outpatient and ambulatory surgery center payments for next year, and also outlining a potential remedy to private Medicare overpayments.
The Centers for Medicare & Medicaid Services is proposing a 2.1 percent increase for outpatient payments and a 1.2 percent increase for ambulatory payments, as long as both entities submit quality data.
Medicare is now legally required to reduce both outpatient ambulatory surgery center payments to providers that don’t submit quality data covering a range of clinical areas. But after other payment factors are considered, the agency says hospitals that don’t report will actually see a hair of an outpatient raise – 0.1 percent – while ambulatory surgery centers that don’t report will get a 0.8 percent reduction.
Under the proposed rule (comments welcome until Sept. 8), total hospital outpatient payments for the 2015 calendar year will reach to more than $56 billion, a year-over-year increase of $5 billion “or $800 million excluding our estimated changes in enrollment, utilization, and case-mix,” CMS regulators wrote in the 687 page proposed rule.
About 4,000 hospital outpatient facilities will be affected, including general acute care hospitals, children’s hospitals, cancer hospitals and community mental health centers, with some getting specific payment adjustments. Rural sole community hospitals and essential access community hospitals will both get 7.1 percent increases.
For ambulatory surgery centers, the agency expects that total payments under the proposed rule will increase by $243 million, to more than $4 billion. Regulators are also seeking more comprehensive but consolidated ambulatory payment classifications for expensive device services and proposing to narrow a list of 39 device-dependent services to 26, including for pacemakers, neurostimulators and musculoskeletal devices.
Unlike the outpatient payment system, “there is currently no mechanism within the ASC claims processing system for ASCs to submit to CMS the actual amount received when furnishing a specified device at full or partial credit,” CMS regulators wrote. “Therefore, under the ASC payment system, we finalized our proposal to continue to reduce ASC payments by 100 percent or 50 percent of the device offset amount when an ASC furnishes a device without cost or with full or partial credit, respectively.”
Current hospital and surgery quality measures include assessments of process of care, patient safety, volume, imaging patterns, care transitions, ED throughput efficiency, information technology and care coordination. CMS is under pressure from Congress and the hospital and medical communities to make quality measures both more relevant and easier to report. For 2017, the agency wants to incorporate new data points, including measures of partial hospitalizations, and reporting means, including electronic clinical quality measures, which could “significantly reduce the administrative burden on hospitals.”
CMS is also proposing to change the required data sources used for expansion requests by physician-owned hospitals under the physician self-referral regulations, and a three-level appeals process for Medicare Advantage organizations and Part D sponsors that would then be used for agency-identified overpayments.
“(O)ur approach thus far to these kinds of situations has been to request that MA organizations and Part D sponsors make these kinds of data corrections voluntarily,” regulators wrote. “However, in instances in which the MA organization or Part D sponsor fails to make the requested data correction, the payment amount calculated for the plan may also be incorrect. As a result, we have concluded that CMS needs to establish a formal process that allows us to recoup overpayments that result from the submission of erroneous payment data.”