CMS to reprocess certain outpatient department claims by Nov. 1

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CMS will reprocess calendar year 2019 claims for outpatient services provided at excepted off-campus, provider-based departments because of an appeals court ruling on site-neutral payments, the agency said Sept. 9.

The agency will begin automatically reprocessing the claims by Nov. 1. The excepted off-campus, provider-based departments will be paid at the same rate as nonexcepted departments.

Under the 2019 Medicare Outpatient Prospective Payment System final rule, CMS made payments for clinic visits site neutral by reducing the payment rate at excepted off-campus, provider-based departments at the same rate as nonexcepted departments. Previously, CMS often paid more for the same time of clinic visit in the hospital outpatient setting than in the physician office setting.

The American Hospital Association sued over the site-neutral payment policy, and, in 2019, a federal judge ruled that CMS exceeded its statutory authority when it cut payments for hospital outpatient services provided in off-campus, provider-based departments excepted under the Bipartisan Budget Act of 2015.

However, a panel of appellate judges in July 2020 overturned the lower court ruling and held that HHS' site-neutral payment policy can go forward.

CMS initially reprocessed the claims to repay the cuts, but now the agency will reinstate the cuts. 

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