CMS' proposed outpatient payment rule for 2019: 10 things to know

CMS released its 2019 Medicare Outpatient Prospective Payment System proposed rule July 25, which calls for site-neutral payments and would make changes to the 340B program.  

Here are 10 things to know about the 2019 proposed rule:

Payment update 

1. CMS proposed increasing the OPPS rates by 1.25 percent in 2019. The agency arrived at its proposed rate increase through the following updates: a positive 2.8 percent market basket update, a negative 0.8 percentage point update for a productivity adjustment and a negative 0.75 percentage point adjustment for cuts under the ACA.

Site-neutral payment proposal

2. Under the proposed rule, CMS would make payments for clinic visits site-neutral by reducing the payment rate for hospital outpatient clinic visits provided at off-campus provider-based departments to 40 percent of the OPPS rate. The clinic visit is the most common service billed under the OPPS, and CMS estimates the payment proposal would save the Medicare program and Medicare recipients a combined $760 million in 2019.

3. This change is projected to reduce OPPS payments by 1.2 percent, which would largely offset the 1.25 percent payment rate increase under the proposed rule.

Proposed 340B program changes

4. CMS scaled back the 340B drug discount program in 2018, and the agency proposed additional cuts for next year.

5. On Jan. 1, 2018, CMS began paying hospitals 22.5 percent less than the average sales price for drugs purchased through the 340B program. That's compared to the previous payment rate of average sales price plus 6 percent.

6. Under the proposed rule, CMS would extend the average sales price minus 22.5 percent payment rate to 340B drugs provided at nonexcepted off-campus provider-based departments.

7. CMS also proposed to pay for separately payable biosimilars acquired under the 340B program at the average sales price minus 22.5 percent of the biosimilar's own ASP, rather than ASP minus 22.5 percent of the reference product's ASP.

Hospital Outpatient Quality Reporting Program changes

8. For 2019, CMS proposed removing one measure from the Hospital Quality Reporting Program beginning with the 2020 payment determination and removing nine other measures beginning with the 2021 payment determination.

9. "The proposals to remove these measures are consistent with the CMS' commitment to using a smaller set of more meaningful measures and focusing on patient-centered outcomes measures, while taking into account opportunities to reduce paperwork and reporting burden on providers," CMS said in the fact sheet for the proposed rule.

Comment period

10. CMS will accept comments on the proposed rule until 5 p.m. EST Sept. 24.

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