Thursday, April 4, 2024

Outpatient Payments In 2022: What’s On The Table

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Outpatient Payments In 2022

The payment calendar year (CY) for the outpatient setting is almost oncoming. It begins January 1, 2022, includes all that we do in the outpatient and ambulatory surgery arenas and sets payments covered by the physician payment schedule. These Centers for Medicare & Medicaid Services (CMS) rules follow the agency’s payment philosophies.

They also take into consideration other programs or mandates that have been set, sometimes by external agencies. Although it might seem challenging to read through the explanations confirming the decisions that CMS has reached, this background data can guide you through the decisions that your facility will be making in the future.


Common themes for 2022 include importance on health equity and patient access to create a medical care system that results in better availability, quality, affordability, legitimize and modification. The approach of CMS to outpatient reimbursement also touches on multiple sides of health care, from requirements for price clearness to increased reimbursement rates for mobile surgery centres and a variety of efforts toward patient safety.

In this proposed rule, CMS is proposing many modifications designed to increase compliance and reduce hospital workload starting January 1, 2022, including the following: 

Proposed Increase in Civil Monetary Penalties (CMP): 

CMS is seeking comment on additional criteria that could be used to scale a CMP, like hospital funds, the nature, scope, severity, and period of non-compliance, and the hospital’s reason for non-compliance. 

Proposing to Consider State Forensic Hospitals as Having Met Requirements

CMS proposes modifying the hospital price transparency regulation’s regarding policy to include state forensic hospitals to meet requirements. So long as such facilities provide treatment simply to people in the custody of penal authorities and don’t offer services to the public. 

Proposing to Prevent New Specific Limitations to Access to the Machine-Readable File

CMS suggests updating the activity list that presents barriers to the machine-readable file, especially requiring that the machine-readable file is accessible to automated searches and direct downloads.

Clarifications and Seeking Comment

CMS explains the expected output of hospital online price estimator tools if a hospital chooses to use an online price estimator tool instead of posting its standard charges for 300 shoppable services in a consumer-friendly format. Specifically, CMS clarifies that an online price estimator tool must provide a cost estimate that takes the individual’s insurance information into account. The forecast reflects the individual will pay the amount the hospital anticipates for the shoppable service, absent unusual or unforeseeable circumstances.

Additionally, CMS is inquiring public input on a variety of problems it may consider in future modifications, including:

· Deliberations for ‘best practice’ online price estimator tools;

· Improving expectations related to ‘plain language descriptions of shoppable services;

· Methods to identify and highlight model hospitals; and

· Improving standardization of the machine-readable files. 

Payment Terms

Payment Updates: The final rule increased clinic payment rates that meet applicable quality reporting requirements by 2%. This update is based on the estimated hospital market increase of 2.7%, decreased by 0.7% points for the productivity adjustment.

Adjust Data Set: Because of several COVID-19 public health emergency-related factors, CMS believes that the CY 2020 data are not the best general view of expected outpatient hospital services in CY 2022. Therefore, they used CY 2019 data to set the CY 2022 OPPS and the ASC payment system rates.

Clinical Charge Transparency: The final rule required a minimum CMP of $300 per day for hospitals with 30 or fewer beds. A discipline of $10 per bed per day would apply to hospitals with a bed count more significant than 30, not to exceed a maximum daily dollar amount of $5,500. Under this strategy, for a full calendar year of non-compliance, the minimum total amount would be $109,000 per hospital, and the maximum total amount would be $2,007,000 per clinic. CMS also finalized its plan to require that machine-readable files be accessible to automated searches and direct downloads.

340B-Obtained Drugs: The rule maintained the payment rate of average sales prices minus 22.5% for specific payable drugs or biologics obtained through the 340B Drug Pricing Program.

Site-Neutral Payments: Payment cutbacks for hospital outpatient clinic visits (HCPCS code G0463) are continued when furnished by excepted off-campus, provider-based departments.

Inpatient Only (IPO) List: The final rule prevented exclusion of the IPO list and returns the priority of the services removed in CY 2021, except for CPT codes 22630, 23472, 27702, and their similar anesthesia codes. The rule codifies longstanding criteria for removing procedures from the IPO list to clarify how future systems will be evaluated for removal in the regulatory text. The government also releases methods removed from the IPO list starting on or after January 1, 2022, from site-of-service and non-compliance with the Two-Midnight Rule for two years.

ASC Covered Procedures List (ASC CPL): The rule replaced patient safety guidelines for adding a procedure to the ASC CPL in place in CY 2020 and removed from the ASC CPL 255 techniques added in CY 2021. The final rule also assumes a nomination process that, starting March 2022, will allow an outside party to propose a surgical procedure to add to the ASC CPL. For example, suppose CMS identifies that a surgical process meets the requirements to add to the ASC CPL, including a surgical technique nominated by an outside party. In that case, it will propose to add the surgical procedure to the ASC CPL for January 1, 2023. CMS will provide sub-regulatory intelligence on the nomination process in early 2022.

ASC Payment for Non-Opioid Products: The rule modified the current CY 2022 that provides separate charges for non-opioid pain management drugs and biologicals that work as supplies in the ASC setting. When such product is Food and Drug Administration (FDA) approved, specified for pain management or as a pain killer by the FDA, and has a per-day charge above the OPPS drug packaging entry.

Beneficiary Coinsurance for Colorectal Cancer Screening Tests: Flexible sigmoidoscopies and colonoscopies are considered screening in the final rule, anyhow of whether tissue or other matter is removed during the screening test beginning January 1, 2022. The government gradually reduces beneficiary cost-sharing for these services starting January 1, 2022, so that for services appointed on or after January 1, 2030, the coinsurance will be zero.

Outpatient Quality Reporting (OQR) Program

The final rule approved three new measures:

· Screening recall rates of breast cancer (OP-39) is claims-based and begins with a data collection period of July 2020 to June 2021.

· COVID-19 vaccination coverage among medical care personnel measure (OP-38) starts with CY 2022 reporting to the Centers for Disease Control and Prevention through the National Healthcare Safety Network system.

· ST-Segment Elevation Myocardial Infarction (STEMI) eCQM (OP-40) will start with one-quarter of data for CY 2024 reporting, after a year of voluntary reporting in CY 2023. Two chart-abstracted measures, OP-2 and OP-3, are removed as a result, and these areas will no longer need to be reported starting with CY 2023 reporting.

The final rule is also called the reporting of the Outpatient and Ambulatory Surgical Consumer Assessment of Healthcare Providers and Systems, or OAS CAHPS, and the waters measure starting with CY 2024 reporting and CY 2025 reporting, respectively.

The rule also updated the validation plans to minimize the reporting period from 45 days to 30 days, starting with validations of CY 2022 reporting.

CMS also examined comments the agency received in return to requests for data regarding a transition to digital quality measurement and acknowledging health equity in hospital quality programs.

Unique points from the OPPS rule:

  • Use of calendar year (CY) 2019 requests data for CY 2022 OPPS and Ambulatory Surgery Center (ASC) Payment System rate-setting due to the COVID-19 Public Health Emergency.
  • Take a decision to stop excluding the Inpatient Only (IPO) List for CY 2022, based on powerful stakeholder feedback during the 2021 rulemaking cycle. CMS added back more than 295 services removed from the IPO list last year. Additionally, CMS codified the longstanding criteria for the removal of procedures from the IPO list.
  • Replace the ASC Covered Procedures List (ASC CPL) criteria and remove 255 of the 267 processes from the ASC CPL that were added in CY 2021. A new selection process for adding services to the CPL was adopted to allow an outside party to nominate a surgical procedure to add to the ASC CPL in the next applicable rulemaking cycle.
  • The rule accepted multiple device pass-through payments, including the AngelMed Guardian device and the Shockwave C2 Coronary Intravascular Lithotripsy (IVL) catheter.

Price Clarity of Hospital Standard Charges

The Hospital Charge Transparency final rule became effective on January 1, 2021. This final rule carries out some sections of the Public Health Service Act. It needs every clinic operating within the United States to establish and make public a yearly list of the hospital’s standard charges for items and services, including diagnosis-related groups based under a section of the Social Security Act. 

CMS ensures consumers have the information they need to make fully informed decisions regarding their medical care. Hospital cost clearness helps people know what hospital charges for the items and services it provides. CMS expects hospitals to follow these legal obligations and make these rules to ensure people understand what hospitals charge for items and services.

The Hospital Price Transparency final rule established regulations at 45 CFR 180 and included the following:

  1. Definitions of “clinic,” “regular prices,” and “objects and assistance.”
  2. Requirements for making public a machine-readable file online include all standard charges for all hospital items and services. (mainly, gross charges, payer-specific negotiated charges, discounted cash prices, and de-identified minimum and maximum negotiated bills) 
  3. Establish requirements for making public standard charges for a limited set of ‘shoppable’ services that are displayed and packaged in a consumer-friendly manner or use of an online price estimator tool.
  4. Monitoring for hospital non-compliance and actions to address hospital non-compliance (including issuing a warning notice, requesting a corrective action plan, and imposing civil financial fines of $300/day), and a process for hospitals to review these disciplines.


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