On July 15, the Centers for Medicare & Medicaid Services (CMS) released one of its largest annual payment proposed rules – the Hospital Outpatient Prospective Payment System (OPPS) for the calendar year (CY) 2023. The OPPS rule governs “changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the Ambulatory Surgical Center (ASC) payment system,” as well as changes to associated quality reporting programs. ASHP is reviewing the 800-page proposed rule and will publish an issue brief in the coming days outlining key provisions of interest to our members. In the interim, ASHP has provided highlights below.
Hospital Outpatient Prospective Payment System
- 340B: Due to the timing of the recent Supreme Court decision that CMS’s cut to 340B reimbursement in Medicare Part B was unlawful, CMS has maintained the average sales price (ASP) minus 22.5% payment for 340B drugs in the proposed rule. However, the agency indicates it plans to increase payment to ASP plus 6% in the CY 2023 final rule. Additionally, CMS is seeking comment on how to remedy the underpayment for 340B drugs since CMS first instituted the reimbursement cut in 2019. ASHP will be seeking feedback from members regarding potential solutions for reimbursing hospitals for the 340B underpayment during the affected years.
ADVERTISEMENT - Payment for Non-Opioid Pain Management: CMS is continuing to implement the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act by ensuring patients have access to non-opioid therapies. To avoid disincentivizing the use of non-opioid pain management drugs, CMS proposes separate payment for four drugs that function as surgical supplies – bupivacaine injection, phenylephrine and ketorolac ophthalmic irrigation solution, bupivacaine and meloxicam instillation, and bupivacaine collagen-matrix implant. CMS is seeking feedback on additional non-opioid products that should be separately paid when used as surgical supplies.
- Rural Sole Community Hospital Site Neutral Payment Exemption: Over the past several years, CMS has implemented a site-neutral payment policy for off-campus provider-based departments establishing a clinic visit fee equivalent to the Physician Fee Schedule (PFS) rate. However, due to concerns about patient access, CMS proposes to exempt Rural Sole Community (RSC) Hospitals from the site-neutral changes by paying for clinic visits furnished at an RSC’s excepted off-campus provider-based departments at the full OPPS rate (approximately 60% more than the PFS rate).
- Payment Adjustments for Domestically-Produced N95s: To incentivize the purchase of domestically-produced N95s, CMS proposes to provide a payment adjustment in both the hospital inpatient and outpatient settings. Specifically, CMS proposes to offset the “additional marginal resource costs that hospitals face in procuring domestically made NIOSH-approved surgical N95 respirators” by making biweekly lump-sum payments to hospitals that are then reconciled at cost report settlement.
In addition to the highlights above, CMS is proposing changes to behavioral health services provided in beneficiary’s homes, to the inpatient only list and ASC procedure list, payment for software as a service (i.e., clinical decision-making support tools), and to the OPPS and ASC quality reporting programs.
ASHP will be seeking member input to inform our comments on OPPS, which are due in September. Please email feedback on the proposed rule to Jillanne Schulte Wall, ASHP senior director of health and regulatory policy, at [email protected] by August 30.
