CMS Delivers Flurry of Final Rules

Changes to the MPFS, OPPS, and HHPPS were announced on the same day.

Rather than a “news dump” late on a Friday afternoon, federal healthcare officials instead served up a “final rule dump” late on a Tuesday afternoon.

The Centers for Medicare & Medicaid Services (CMS) issued three comprehensive final rules on the same day last week, heralding changes to the Medicare Physician Fee Schedule (MPFS), the Outpatient Prospective Payment System (OPPS) as it pertains to Ambulatory Surgical Centers (ASCs), and the Home Health Prospective Payment System (HHPPS).

Stanley Nachimson, principal of Nachimson Advisors, a health IT consulting firm, and a longtime contributor to RACmonitor and ICD10monitor, may have said it best during the most recent edition of Talk-Ten-Tuesdays.

“We may have to have a special ‘Washington Wednesday’ broadcast,” he mused, “if this keeps happening.”

MPFS Final Rule
According to Nachimson, other key policies in the Final Rule include:

  • A reduction in the base rate used to calculate the payment rate for services based on the Relative Value Units (RVUs) assigned to services. This is based on several legislative requirements and the end of a 3.75-percent “bonus” included in last year’s budget legislation.
  • An update to the clinical labor rates that are used to calculate practice expense under the MPFS. As a result, payments to primary care specialists that involve more clinical labor, such as family practice, geriatrics, and internal medicine specialties, are expected to increase.
  • Implementation of coverage of certain mental and behavioral health services via audio-only telephone calls.
  • Allowing physician assistants to bill Medicare directly.
  • Removal of a requirement that limited who could refer people with Medicare to medical nutrition therapy services, allowing any physician (M.D. or D.O.) to do so. This change should particularly benefit people living in rural areas, as such services are provided to eligible individuals with no out-of-pocket costs, and may be provided via telehealth.
  • Finalization of a higher performance threshold that clinicians will be required to exceed in 2022 to be eligible for positive payment incentives under the QPP.
  • Refinement of current policies for split (or shared) evaluation and management (E&M) visits, critical care services, and services furnished by teaching physicians involving residents, based on changes in the CPT codebook.

The MPFS Final Rule also finalized changes to the Medicare Diabetes Prevention Program (MDPP) expanded model.

“These policies are intended to boost supplier enrollment, with the goal of increasing beneficiary participation and access to services that can help them develop and maintain healthy behaviors to prevent onset of type 2 diabetes,” CMS explained in a fact sheet issued on the topic. “We anticipate that these final changes will make it easier for local suppliers to participate and reach their communities. If the anticipated increased participation occurs, this will allow CMS to perform a more robust evaluation of the expanded model.”

OPPS/ASC Final Rule
Modification of the hospital price transparency regulation designed to increase compliance, including raising civil monetary penalties for non-compliance with a minimum of $300 per day;

  • An update to the OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.0 percent for 2022;
  • Halting the elimination of the Inpatient-Only (IPO) List, and adding back to the List the services removed in 2021, except for CPT codes 22630 (Lumbar spine fusion), 23472 (Reconstruction of shoulder joint), 27702 (Reconstruction of ankle joint), and their corresponding anesthesia codes;
  • Removal of 255 of the 258 procedures proposed for removal from the ASC covered procedure list; and
  • Updates to measures for the outpatient hospital and ASC quality programs.

In a press release announcing the changes, CMS said it anticipates that the moves will “further advance its commitment to increasing price transparency, holding hospitals accountable, and ensuring consumers have the information they need to make fully informed decisions regarding their healthcare.”

“CMS is committed to promoting and driving price transparency, and we take seriously concerns we have heard from consumers that hospitals are not making clear, accessible pricing information available online, as they have been required to do since January 1, 2021,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “We are also taking actions to enhance patient safety and quality care.”

The $300-per-day fines related to price transparency will apply to smaller hospitals with a bed count of 30 or fewer, with a penalty of $10 per bed per day levied against hospitals with a bed count greater than 30, not to exceed a maximum daily amount of $5,500, CMS noted. Under this approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, with the maximum set at a lofty $2,007,500 per hospital.

HHPPS Final Rule
Lastly, Nachimson noted that the HHPPS Final Rule:

  • Finalizes a nationwide expansion of the successful Home Health Value-Based Purchasing (HHVBP) Model;
  • Updates Medicare home health agency (HHA) payment rates and the wage index for HHAs for the 2022 calendar year, in accordance with existing statutory and regulatory requirements. CMS estimates that Medicare payments to HHAs would increase in the aggregate by $570 million (3.2 percent) next year;
  • Updates the payment rates for home infusion therapy services, an increase to such suppliers of 5.1 percent; and
  • Updates the quality measurement program for HHAs and makes permanent several waivers granted under the current COVID-19 public health emergency (PHE), including blanket waivers related to home health aide supervision and the use of telecommunications in conducting assessment visits.

In a press release, CMS described the changes as collectively representing a “strategic commitment to drive innovation that promotes comprehensive, person-centered care for older adults and people with disabilities by accelerating the shift from paying for home health services based on volume, to a system that incentivizes value and quality.” Officials said the final rule would also strengthen CMS’s data collection efforts to identify and address health disparities and use of care among people who are dually eligible for Medicare and Medicaid, people with disabilities, people who identify as LGBTQ+, religious minorities, people who live in rural areas, and people otherwise adversely affected by persistent poverty or inequality.

“CMS is committed to helping people get the care they need, where they need it,” Brooks-LaSure said in a statement. “This final rule will improve the delivery of home health services for people with Medicare. It will also improve our data collection efforts, helping us to identify health disparities and advance health equity.”

The CMS Innovation Center launched the original HHVBP Model in January 2016, to determine whether CMS could improve the quality and delivery of home health services to people with Medicare by offering financial incentives to providers that offer better quality of care with greater efficiency, officials noted.

The original HHVBP Model comprised all Medicare-certified HHAs providing services across nine randomly selected states. The Third Annual Evaluation Report of the participants’ performance from 2016-2018 showed an average 4.6 percent improvement in quality scores and an average annual savings of $141 million to Medicare.

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