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Jul 09, 2014

CY 2015 OPPS/ASC Proposed Rule Makes Refinements to Last Year’s Significant Changes to the Outpatient Payment System

Published

Jul 09, 2014

On July 3, CMS released the Calendar Year (CY) 2015 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule.

The rule implements and refines comprehensive Ambulatory Payment Classifications (C-APCs) and expands packaging to include additional low cost/ancillary diagnostic and therapeutic services. While the proposed changes are smaller than CY 2014 (which represented the most significant system overhaul since CY 2008), CMS continues to emphasize larger payment bundles and consolidation of APCs as mechanisms to drive hospital efficiencies.

Hospital Outpatient Department (HOPD) and ASC payments for facilities meeting quality reporting requirements are proposed to increase by 2.1 percent and 1.2, respectively.  CMS’ continued emphasis on encounter-based payments and expanded packaging will result in additional downward pressure on hospitals to reduce costs to maximize payments and avoid losses on individual cases.

Payment for pass-through products and specified covered outpatient drugs (SCODs) are expected to continue at Average Sales Price (ASP) + 6 percent.  The packaging threshold for non-pass-through products is proposed at $90, stable from CY 2014. CMS will implement C-APCs, postponed from CY 2014, with some refinements to the methodology and restructuring of underlying APCs.  CMS proposed to continue to segment packaged payment for skin substitutes based on cost, but the methodology for determining high or low cost would be revised from an ASP-based determination to one based on weighted average mean unit cost (MUC). CMS also proposes to consider skin substitutes as medical devices for the purposes of determining pass-through status, requiring them to meet the higher device pass-through hurdle of demonstrating substantial clinical improvement over existing items and services.  CMS proposes to continue last year’s exemption for packaging of drug administration procedures, but hints at a potential overhaul in the payment methodology for these services in future rulemaking. 

Comments are due to CMS by Sep. 2, and a final rule will be released in November. 

View CMS’ proposed OPPS/ASC rule.

For more specific OPPS/ASC questions, contact Robert Gerson at RGerson@Avalere.com or Carrie Bullock at CBullock@Avalere.com. 

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