Key Takeaways from CMS Proposed Rule 2019

Recently CMS issued the proposed rules for 2019 Outpatient Prospective Payment System and Medicare Physician Fee Schedule. Both of these rules have significant reimbursement changes. However; these changes are yet to be finalized.

The key takeaways from CMS proposed rule mentions:

There will be a single payment rate for Level 2-5 ( Evaluation and Management visits)

CMS proposes a single rate that would apply to all Level 2 through Level 5 visits for new and established patients. New patient visits would be reimbursed at a rate of $135 for Level 2-5 visits; established patient visits would be reimbursed at a rate of $93.

With this new payment practice; the providers will see a significant rise in the reimbursement rates which will be about 79% to 81% hike for the Level 2 visits.

Under the existing structure, Level 4 and Level 5 visits for new patients are reimbursed respectively at rates of $167 and $211.

Reduced payment for clinic visits

CMS would extend site neutrality beyond that approved by Congress in Section 603 of the Bipartisan Budget Act. This proposal arguably exceeds CMS’ rulemaking authority.

CMS proposes to increase the present non-excepted off-campus PBD reimbursement diminutions to all off-campus PBDs.

As a result, all evaluation and management clinical visits at off-campus PBDs will be receiving 42% of the OPPS reimbursement. For example, the OPPS payment for a clinic visit is approximately $116; payment under the new PFS equivalent rates would be approximately $46. For most PBDs, clinical reimbursement is the main source of revenue.

Limitations of the expansion at grandfathered off-campus provider-based departments

CMS seeks to revise the capability of grandfathered PBDs receiving OPPS reimbursement to increase their service lines.

Under the proposed rule CMS is looking forward to limiting the services which were earlier reimbursed under the OPPS. Now it will be reimbursed who meets the clinical families of the services test.

Any of these services which don’t meet the test requirements will be reimbursed underneath the lower PFS-equivalent rate, a reduction of approximately 61%.

Expansion of 340B payment cuts

In the proposed rule CMS anticipates increasing these cuts to all 340B drugs provided at non-excepted off-campus PBDs. Therefore, the child sites which joined under the 340B Program as DSHs, RRCs, or urban SCHs now will be subjected to a 27% reduction from the start of this January month.

Reduced Medicare Part B drug reimbursement

CMS proposes to cut WAC reimbursement rates to WAC plus 3%, beginning in January 2019. While the stated intent of these cuts is to lower overall drug costs to beneficiaries, this action is more likely to lead to price increases for most manufacturers’ new drugs in order to match the reimbursement rates of competitors.

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