Nov 6, 2018
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CMS significantly expands its Medicare site-neutral payment policy

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We previously summarized certain provisions of CMS’s CY 2019 OPPS/ASC final rule published on November 2. See here. In this final rule CMS significantly expands its Medicare site-neutral payment policy beginning January 1, 2019.

As we previously described, CMS did not finalize its proposal that an excepted off-campus provider-based department (PBD) will be paid under the Medicare outpatient prospective payment system (OPPS) for a service only if that service was within 19 “clinical family of services” and a service within that clinical family of services had been furnished in the PBD before November 2, 2015 (the date of enactment of the Bipartisan Budget Act of 2015 (BBA)) and billed to Medicare. Accordingly, in CY 2019 an excepted off-campus PBD will continue to receive payments under the OPPS for all billed items and services that are paid under the OPPS, regardless of whether that PBD had furnished such service or another service within that clinical family of services prior to November 2, 2015, provided the excepted off-campus PBD remains excepted, that is, it continues to meet the relocation and change of ownership requirements adopted in the CY 2017 OPPS/ASC final rule. CMS did indicate that while it is not finalizing this proposal at this time, it intends to monitor the expansion of services in excepted off-campus PBDs and, if appropriate, propose to adopt a limitation on the expansion of excepted services in future rulemaking.

Significantly however, while CMS decline to implement this proposal, the agency did finalize its proposal to expand its site-neutral payment policy to clinic visit services performed in excepted off-campus PBDs. Specifically, in CY 2019, a clinical visit service as described by HCPCS code G0463 when furnished in an excepted off-campus PBD will only be paid 70 percent of the OPPS rate. In CY 2020 and subsequent years, the payment rate for these services will be further decreased, specifically, excepted off-campus PBDs will be paid the site-specific Medicare Physician Fee Schedule rate for a clinic visit service, that is 40 percent of the OPPS rate.  It is reported that the American Hospital Association and the Association of American Medical Colleges on behalf of their member hospitals will file a lawsuit arguing that CMS’s expansion of its site-neutral payment policy to excepted off-campus PBDs is inconsistent with the BBA, Section 603.

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