Embed Size (px)
Citation preview
Recap of Provider-Based Changes in the Bipartisan Budget Act of 2015 & Overview of CMS' Proposed Rules
Presenters: • Bragg E. Hemme, Shareholder, Polsinelli, PC• Julius W. Hobson, Jr., Senior Policy Advisor, Polsinelli, PC• Lauren Z Groebe, Associate, Polsinelli, PC
Back to the Future … Will CMS’ Proposed Provider-Based Rules Reshape the Future? Or
Will They Rewrite the Past?
July 19, 2016
PolsinelliReimbursement Institute
Polsinelli Reimbursement Institute
Single source of news, information and guidance on the constantly evolving reimbursement industry– eAlerts– Webinars– News from D.C.– Links to current guidance– Advisors
http://www.polsinelliri.com/
2
Part 1: Roadmap
Part I – Where we are today Recap of Section 603 CMS Proposed Rule Implementing Section 603 Legislative Landscape
Part II – Where we are headed in 2017 Thursday, July 28, 2016 Practical implications of Proposed Rule Review of scenarios impacted by Proposed Rule Review of potential 340B implications Overview of critical comment areas
3
The Path Leading Up to CMS’ Proposed Changes to Provider-Based Rules
4
SITE NEUTRAL PAYMENTS BACKGROUND
MedPAC March 2012 Report to Congress recommended Congress
“reduce payment rates for evaluation and management office visits provided in hospital outpatient departments so that total payment rates for these visits are the same whether the service is provided in an outpatient department or a physician office”
Subsequent MedPAC reports to Congress [June 2013, March 2014, & March 2015] included the same proposal
5
SITE NEUTRAL PAYMENTS BACKGROUND
The President’s Fiscal Year 2016 budget proposal: – Included a proposal to equalize site-of-service
payments between hospital outpatient departments and physicians’ offices;
– Proposal called for a four-year phase-in period; and
– Projected savings were estimated to be $29.5 billion over 10 years.
6
Sect. 603 of the BIPARTISAN BUDGET ACT OF 2015
Site-Neutral Problem:– Generally, two Medicare payments for services
furnished in off-campus provider-based hospital outpatient departments:
• Outpatient prospective payment system (OPPS) facility fee; and• Professional services under Medicare Physician Fee Schedule.
– Generally, Medicare reimbursement (and patient coinsurance obligations) greater for services provided in provider-based hospital outpatient departments than freestanding physician clinics or ambulatory surgical centers.
7
Sect. 603 of the BIPARTISAN BUDGET ACT OF 2015
Site-Neutral Solution:– Effective November 2, 2015– Amended Social Security Act Section 1833(t)– Prohibits development of “new, off-campus” provider-
based hospital outpatient departments by ceasing payment under the hospital OPPS after December 31, 2016
– Several specific exceptions – CBO estimated $9.3 billion in savings over ten years– Section 603 added at the request of the Administration– Provision has no published legislative history
8
Sect. 603 of the BIPARTISAN BUDGET ACT OF 2015
Effective January 1, 2017, “new, off-campus” provider-based hospital outpatient departments will be paid under another available Medicare payment system, depending upon that facility’s service type– “New” = submits a claim to Medicare for a OPPS service for the first
time after November 2, 2015– “Off-campus” = any department that is located more than 250
yards from the main hospital (though this range may be slightly extended by regional offices on a case-by-case basis) or from a remote location of the hospital
9
Sect. 603 of the BIPARTISAN BUDGET ACT OF 2015
Payment will (only) be under MPFS or the ASC payment system (or another payment system), as long as the facility meets all other requirements for payment under that system
Facility must first enroll in Medicare as the applicable supplier-type (clinic, ASC, IDTF or other type)
10
Sect. 603 of the BIPARTISAN BUDGET ACT OF 2015
Section 603 excepts or does not apply to certain Provider-Based Departments/Entities– Off-campus hospital outpatient departments in
existence and billing as provider-based prior to November 2, 2015 (“grandfathered”)
– On-campus hospital outpatient departments– Provider-based entities (e.g., RHCs, certain
FQHCs and FQHC look alikes)– Dedicated emergency departments
11
CMS Proposed Rule Implementing Section 603:Major Themes
81 Fed. Reg. 45604, 45681 (July 14, 2016)
12
Excepted Items and Services
CMS proposed that certain off-campus provider-based hospital outpatient departments (“PBDs”) items and services will be “excepted” – If excepted, can continue to bill under the OPPS
These excepted items and services include:– All items and services furnished in a dedicated emergency
department (as defined in 42 C.F.R. § 489.24), regardless whether they are emergency services;
– Those items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015 and other items or services within the same clinical family; and
– Any items and services furnished in a hospital department within 250 yards of a remote location of the hospital
13
Dedicated EDs
All items and services (emergent or not) furnished in a dedicated ED excepted– On- or off-campus– Must meet one of the following requirements:
• Licensed by state as an emergency department• Held out to public as providing care for emergency
medical conditions on an unscheduled, urgent basis• During the prior calendar year, provided at least 1/3 of
visits for treatment of emergency medical condition– Exception includes both emergency and non-
emergency services
14
Existing Definitions
“Department of a Provider” – Current definition includes both the specific physical facility
and the personnel and equipment needed to deliver services at that facility
“Campus”– Physical area immediately adjacent to the provider's main
buildings, other areas and structures that are not strictly contiguous to the main buildings, but are within 250 yards of the main buildings, and any other areas determined on a case by case basis, by the CMS RO, to be part of the campus
No changes to either definition proposed
15
On-/Off-Campus PBD
On-Campus locations excepted Remote locations and PBD within 250 yards of remote
locations still “off-campus,” but has excepted status Measurement of the 250 yards hospital should be
done in a straight line by use of surveyor reports or other appropriate documentation from any point of a remote location
16
Relocation of Off-Campus Provider-Based Hospital Outpatient Departments
CMS proposed to prohibit relocation of existing off-campus PDBs
Existing PBD is identified by street addresses and unit/suite number– Based on locations listed on CMS-855A
Expansion into other suites/units in the same building would be prohibited
Excepted off-campus PBDs would lose their excepted status if relocated
Considering relocation exception for natural disasters
17
Expansion of Services
CMS proposes to limit the ability to expand the types of services offered from excepted off-campus PBDs
Would continue to be paid at OPPS rates for added items and services in the same “clinical families of services”
19 “clinical families of services” defined by HCPCS codes mapped to APCs
Services beyond clinical families of services considered be non-excepted services (i.e., not payable under the OPPS) and must be billed under the MPFS, if at all
18
Clinical Family of Services
Example:– As of Nov. 2, 2015, Hospital maintained a urology
PBD– After Nov. 2, 2015, Hospital purchases physician
practice with GI specialty and seeks to add services to existing, excepted PBD
– Because urology and GI are in different clinical families of services, only urology services would be paid OPPS
• GI service line would not get excepted status
19
Change of Ownership (CHOW)
If a hospital has a change of ownership, the off-campus PBD may maintain its excepted status only if the new owners accept the existing Medicare provider agreement from the prior owner – Traditional Medicare CHOW with successor
Medicare liability Individual off-campus PBDs could not be
transferred from one hospital to another and maintain excepted status
20
Payment for Non-excepted PBDs
2 Medicare payments for PBD services:1. Facility payment under OPPS2. Professional payment under MPFS
– Lower “facility payment; no overhead
Section 603 requires non-excepted items and services to be paid under other applicable [non-OPPS] payment systems
21
Payment for Non-excepted PBDs
CMS delays implementation until CY 2018 Because … CMS cannot develop an alternative
payment system January 1, 2017 However, physicians are instructed to bill for
professional services utilizing the non-facility POS
22
Payment for Non-excepted PBDs
If physician paid the non-facility MPFS rate, what are the hospital’s options?1. Don’t bill – Hospitals would forego payment for
facility/technical/ancillary services 2. Enter into an arrangement with physicians –
Physicians would bill and then pay Hospital for facility/technical/ancillary services; or
3. Enroll and submit claims as another freestanding supplier type (e.g., physician clinic, ASC)
Each option creates a host of practical and legal issues (e.g., Stark, AKS, reassignment)
23
Solicitation of Comments
CMS seeks comments on the following areas:– Information needed to identify non-excepted PBDs– Development of relocation exception process– Development of a specific timeframe to allow an expansion to a related
“clinical family of services”– Proposed categories of clinical families of services– Changes of ownership– Data collection – Changes to enrollment forms, claims forms, hospital cost reports, and
hospital operations– Impact of other existing rules on payment for non-excepted items and
services– Billing for items and services from a non-excepted PBD on the CMS-1500
24
Legislative Action Since Passage of Section 603
25
U.S. HOUSE OF REPRESENTATIVES ACTION
On June 7th, House passed H.R. 5273, the “Helping Hospitals Improve Patient Care Act of 2016”, by voice vote
Legislation would allow providers that were already building new off-campus outpatient facilities to be grandfathered into the outpatient rates
Affects almost 100 hospitals $750 million cost was offset by a small reduction in the hospital inpatient
documentation and coding adjustments required by the “Medicare Access and CHIP Reauthorization Act (MACRA) of 2015”
Maintains current law separate payment system for cancer hospitals providing an exemption from the site-neutral policy and would allow cancer hospitals to continue to be paid at cancer hospital rates at new off-campus locations
Cancer hospital provision offset by a small reduction in the payments to cancer hospitals as calculated by their Payment to Cost Ratio (PCR)
26
U.S. SENATE OUTLOOK
H.R. 5273 was received in the Senate on June 8th and referred to the Committee on Finance
No hearings have been held Polsinelli discussions with Medicare Part A staff Future Finance Committee Medicare legislation Timing
27
HOSPITAL ADVOCATES
American Hospital Association, America’s Essential Hospitals and the Federal of American Hospitals opposed Section 603
All initially called for repeal Later, AHA, AEH, and FAH supported passage of
H.R. 5273 All three have spoken out against several
provisions in the CMS proposed rule
28
SECTION 603 LEGISLATIVE ISSUES
H.R. 5273 only deals with hospitals in the middle of constructing a new/replacement facility
CMS proposed rule includes regulatory interpretations not explicitly discussed in the statute
Some advocacy options:– Support inclusion of House provision in a Senate Medicare bill– Advocate for full repeal ($9.3 billion in budget offsets needed)– Support inclusion of House provision, plus legislative provisions to
offset more onerous CMA regulatory proposals– Support legislative delay of the proposed rule’s implementation
29
Upcoming Webinar Information
Final installment of 2-part webinar series Part II: Where are we headed in CY2017? Date:
– Thursday, July 28, 2016 Agenda includes:
– Practical and operational implications flowing from CMS' proposed rule– Review of hypothetical scenarios impacted by CMS' proposed rule and
those that remain unsolved, including relocation of existing facilities, facilities in development, service line expansions, adding services to an otherwise exempt emergency department, space-sharing, and time-sharing
– Review of potential 340B implications– Overview of critical comment areas
30
Questions??
31
real challenges. real answers. sm
Polsinelli provides this material for informational purposes only. The material provided herein is general and is not intended to be legal advice. Nothing herein should be relied upon or used without consulting a lawyer to consider your specific circumstances, possible changes to applicable laws, rules and regulations and other legal issues. Receipt of this material does not establish an attorney-client relationship.
Polsinelli is very proud of the results we obtain for our clients, but you should know that past results do not guarantee future results; that every case is different and must be judged on its own merits; and that the choice of a lawyer is an important decision and should not be based solely upon advertisements.
© 2016 Polsinelli PC. In California, Polsinelli LLP. Polsinelli is a registered mark of Polsinelli PC
32
