Proposed 2019 Medicare HOPPS Rule: The 4 Things Labs Need to Know

Heads up to labs that bill Medicare for services to hospital outpatients: CMS issued the proposed 2019 hospital Outpatient Prospective Payment System (OPPS) on July 25, with comments scheduled to end on Sept. 24. Highlights:

1. 1.25% Rate Increase

CMS proposes increasing 2019 OPPS rates by 1.25%, based on a:

  • 8% market basket update;
  • -0.8% productivity adjustment update; and
  • -0.75-percentage point adjustment for cuts under the Affordable Care Act (ACA).

2. 40% Site-Neutral Payment

CMS wants to reduce the payment rate for hospital outpatient clinic visits provided at off-campus provider-based departments to 40% of the OPPS rate. The clinic visit is currently the most common service billed under the OPPS. The proposed rule would also cut payments to currently grandfathered sites for certain clinic visit services to address concerns about the trend where more services are shifting away from doctor offices and into hospital outpatient departments.

3. Hospital Outpatient Quality Reporting Program.

CMS is proposing to remove one measure from the Hospital Quality Reporting Program beginning with the 2020 payment determination and remove nine other measures beginning with the 2021 payment determination. “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,” the agency noted in the fact sheet for the proposed rule.

4. Opioid-Related Policies

CMS wants to modify the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey measure by removing three recently revised pain communication questions. The change stems from concerns that providers may feel unduly pressured by patients seeking opioid-based therapies who can, in turn, report the physician neglected their preferences, as well as an intent to avoid any potential unintended consequences of possible opioid overprescribing. In addition, the President’s Commission on Combating Drug Addiction and the Opioid Crisis has recommended that CMS review its payment policies for certain drugs that function as a supply: specifically, non-opioid pain management treatments.


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