Policy changes in the proposed rule include lifting a moratorium at the end of 2013 on enforcing a direct supervision requirement for critical access hospitals and small rural hospitals. That requirement—mandating the round-the-clock presence of physicians, which small rural facilities say they can't afford—has drawn concern from members of Congress representing rural states and is strongly opposed by the American Hospital Association.
The proposed rule also would continue Medicare's move away from fee-for-service and toward a bundled-payment system by expanding the categories of related items and services packaged into a single payment—similar to what is done for inpatient payments.
For the seven new categories of supporting items and services that CMS proposed to make part of a package payment, Medicare would still pay individually if they are reported in separate claims. The new categories include drugs, biologicals and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure.
Larry Vernaglia, chair of the healthcare practice at Foley & Lardner, said the proposed bundled payments are the latest examples of the CMS shift aimed at saving Medicare money. “Obviously, that can't help but reduce reimbursement,” he said in an interview.
The rule also would replace five levels of outpatient visit codes as part of an effort to reduce upcoding. Instead, the agency proposed a single Healthcare Common Procedure Coding System code for each unique type of outpatient hospital visit.
The change “will reduce administrative burden and be easily adopted by hospitals, and will allow a large universe of claims to be utilized for rate setting,” according to the rule.
In addition to the 0.9% increase for ASCs in 2014, the proposed rule would reduce payments by 2% for facilities that fail to meet Medicare Quality Reporting Program requirements.
The proposed rule would adjust payment rates for more than 200 codes where Medicare pays more for services furnished in an office than in an outpatient hospital department or ASC.
As part of the ongoing debate over differing payments for the same services provided in different care settings, Vernaglia said he took it as a good sign that the rule explicitly acknowledged “resource costs required to furnish a service to be higher in a hospital or ASC, which have to meet conditions of participation and conditions for coverage.”
“So they sort of get it,” he said.
In such cases, the rule would limit the physician payment to the total payment that Medicare would make to the practitioner and the facility when the service is furnished in a hospital outpatient department.
Starting in 2016, the CMS proposed five new measures for the outpatient quality reporting program, for which data collection would begin in 2014. The new measures included flu vaccination coverage among healthcare personnel and appropriate follow-up interval for normal colonoscopy in average-risk patients.
In exchange, the CMS proposed to remove OQR measures on the provision of a transition record with certain elements at patient discharge and a cardiac measure on patient referrals.
Meanwhile ASCs would have four new OQR measures added to their quality reporting program in 2016.
The update to the 2016 hospital value-based purchasing program would set performance and baseline periods for the catheter-associated urinary tract infection, central line-associated bloodstream infection, and surgical site infection measures.
The rule would create a second-level independent CMS review process for hospitals beyond the existing administrative appeal.
Other features of the proposed rule would change features of the Medicare electronic health record incentive program that allow eligible professionals to reassign their benefits to Method II Critical Access Hospitals.
The proposed rule would follow up last year's separate payment for transitional care management services with the addition of a separate payment for complex chronic care management services, beginning in 2015. The change was aimed at bolstering primary care services, according to the rule. Complex chronic care management services include regular physician development and revision of a plan of care, communication with other treating health professionals, and medication management. Potential practice standards for complex care coordination management services include a provider's access to an EHR that meets HHS certification standards.
The CMS will accept comments on the proposed rule until Sept. 6, 2013, and will issue a final rule by Nov. 1, 2013.
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