CMS finalized its proposal to establish a process through which hospitals must submit a prior authorization request for a provisional affirmation of coverage before a covered outpatient service is furnished to the beneficiary and before the claim is submitted for processing.
This change will apply to the following five categories of services:. Claims submitted for services that require prior authorization that have not received a provisional affirmation of coverage from CMS or its contractors will be denied. Provisional affirmation does not guarantee payment.
A claim for services may still be denied based on either technical requirements that can only be evaluated after the claim has been submitted for formal processing, or information not available at the time the prior authorization request is received.
While there is no formal appeal of a non-affirmation, there are no limits on the number of times a hospital may resubmit a non-affirmed request, and providers may also appeal any claim that is denied.
The exemption would remain in effect until CMS elects to withdraw it. Providers will be notified that they are exempt from the prior authorization process, or that a prior exemption is being withdrawn, within 60 days of the effective date of the exemption or withdrawal of exemption.
Because the prior authorization process applies only to claims paid under the OPPS, services provided outside of the hospital outpatient setting, such as in a physician office or ASC, will not be subject to the prior authorization process. The Medicare wage index seeks to adjust hospital payments to account for how much labor costs vary in different areas of the United States.
For FY , CMS made a variety of changes to the method for calculating the wage index under the IPPS, many of which were intended to support rural providers by narrowing the gap between urban and rural wage index values.
The wage index value of an affected hospital will increase by half the difference between the otherwise applicable wage index value for that hospital and the 25th percentile wage index value across all hospitals. Based on the data for the final rule, the 25th percentile wage index value across all hospitals is 0.
Hospitals with wage index values below 0. This policy will be effective for at least four years. Beginning in , CMS implemented a policy that reduced OPPS payments for clinic visits described by HCPCS code G and furnished by off-campus provider-based outpatient departments that previously were excepted or grandfathered from site-neutral payment policies.
In the rulemaking, CMS decided to phase-in the payment reduction over two years. This change is controversial and the subject of litigation. In September , a federal district court sided with the hospital plaintiffs, ruling that CMS lacked statutory authority to implement the change.
CMS acknowledged the district court decision but indicated that the agency is considering an appeal and does not believe it is appropriate to change the two-year phase-in of the policy at this time. The CY Medicare OPPS final rule provides no relief for hospitals that had Medicare payments for drugs purchased under the B drug discount program cut pursuant to a change.
In December , a federal district court concluded that CMS exceeded its authority when it implemented this policy change. In May , the court determined that the rule that extended the rate reduction to non-excepted i.
The government filed an appeal on the same day. In the proposed CY update, CMS proposed to continue the — payment reductions through for B-acquired drugs.
CMS finalized a change to the minimum required level of supervision for hospital outpatient therapeutic services from direct supervision to general supervision for services furnished by all hospitals and critical access hospitals. CMS stated that the direct supervision requirement for hospital outpatient therapeutic services placed additional burden on providers and reduced their flexibility to provide medical care.
In the proposed rule, CMS sought public comments on whether specific types of services, such as chemotherapy administration or radiation therapy, should be excepted from the change to the supervision requirements. CMS finalized the proposal to apply to all services, including chemotherapy and radiation therapy services. In addition to finalizing its proposal to remove total hip arthroplasty, CMS removed six spinal procedures and five anesthesia codes related to codes that had already been removed from the IPO list.
Jessica is a skilled health care regulatory and policy strategist with a deep understanding of coding, coverage and payment issues impacting a broad array of stakeholders. For clients, Jessica deciphers and navigates complex regulatory and policy issues. Extensive experience utilizing health care data to address regulatory and policy questions, allows her to provide unique insights and solutions. Additionally, she has training This update is based on the projected hospital market basket increase of 2.
The GI societies continue to urge CMS to reduce this gap in the ASC facility fees when compared to the outpatient hospital facility rates, which are estimated to be a roughly 50 percent differential in CY The party who requested the code and provided information for its pricing was not identified. CMS agreed. ASCs will need to report data quarterly on the measure starting January This measure does not financially reward or punish ASCs for their vaccine coverage rate. The latest news from ASGE.
The update of 1. However, due to conflicting calculations, it is unclear how CMS determined this reduced conversion factor. CMS will use the hospital market basket update of 2. This yields an update of 2.
If the CPI-U had been used the update would have been 1.
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