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Welcome to Global Integrated Reimbursement Services’ blog. The purpose of our blog is to allow access to a repository of issues that our company tracks regarding the reimbursement for pharmaceuticals, medical devices, diagnostics, biologics, and biosimilars. Also, it shows you how we can assist you in these areas.

CMS Releases Proposed Changes to Hospital Outpatient Prospective Payment System for 2018

On July 13, 2017, the Centers for Medicare and Medicaid Services (CMS) issued the CY 2018 proposed changes to the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule (CMS-1678-P). We discuss the proposed changes for the OPPS in this blog.

These proposed changes would affect care delivery, drug costs, beneficiary out of pocket cost for several drugs and providers in rural areas. Additionally, CMS is also releasing a Request for Information to gain insight and ideas for regulatory, policy, practice, and procedural changes that would ” better achieve transparency, flexibility, program simplification, and innovation.”

OPPS Proposed Changes
Proposed OPPS Payment Update CMS proposes to update the OPPS rates by 1.75%for 2018. To understand the impact of this payment rate change, please contact us at info@girsinc.com.

Payment with 340B Program Discount To address the issue of increased drug prices and to reduce the cost burden for these drugs on Medicare beneficiaries, CMS proposes to pay separately payable, non pass-through drugs (other than vaccines) at the same rate as the 340B drug pricing program allows – the average sales price (ASP) minus 22.5 percent, rather than ASP plus 6 percent. Applicable drugs not purchased under the 340B drug program would continue to receive ASP plus 6 percent payment.

CMS is seeking comments on whether this payment methodology change should be implemented for participating 340B hospitals and whether there should be exceptions for certain classes of drugs under this methodology. If you would like to comment on this proposal to change the payment methodology for drugs, please contact us at info@girsinc.com.
Direct Supervision Requirement To reduce the burden on physicians in critical access hospitals (CAHs) and rural hospitals, CMS proposes to reinstate the direct supervision moratorium for outpatient therapeutic services for CAHs and small rural hospitals having 100 or fewer beds for CYs 2018 and 2019.

Packaging of Low-Cost Drug Administration Services and supplies in diagnostic testing or surgical procedures: In keeping with the principles of prospective payment, CMS proposes to bundle payments for low-cost and ancillary drug administration add on services. CMS is seeking comment on payment methodologies for drug administration add-on services. CMS is broadly soliciting comments on existing packaging policies under the OPPS, including those related to drugs that function as a supply in a diagnostic test, diagnostic procedure, or surgical procedure. For additional information on this proposal and to comment on it, please contact us at info@girsinc.com.

Inpatient Only List CMS proposes to remove total knee arthroplasty from the inpatient only list. CMS is seeking comment on whether to remove partial and total hip arthroplasty from this list. For additional information on this proposal and to comment on it, please contact us at info@girsinc.com.

High Cost, Low Cost Threshold for Packaged Skin Substitutes CMS is proposing to assign skin substitutes with a geometric mean unit cost (MUC) or a per day cost (PDC) that exceeds either the MUC threshold or the PDC threshold to the high cost group. In addition for CY 2018, CMS is proposing that a skin substitute product that does not exceed either the CY 2018 MUC or PDC threshold for CY 2018, but was assigned to the high cost group for CY 2017, will be assigned to the high cost group for CY 2018. The goal of the proposal is to maintain similar levels of payment for skin substitute products for CY 2018 while CMS analyzes the current skin substitute payment methodology to determine whether refinements to the existing methodologies may be warranted. For additional information on this proposal and to comment on it, please contact us at info@girsinc.com.

Our next article in this series will focus on what you need to know about the proposed 2018 changes to Ambulatory Surgical Center (ASC) Payment System.
The proposed rule will be published on July 20, 2017 and can be found here. CMS will accept comments on the rule through September 11, 2017 and will respond to comments