The Medicare Payment Advisory Commission wants HHS to examine the rise of off-site emergency departments and see whether they are unfairly benefiting from an exemption to the site-neutral payment law.
The CMS currently does not flag payments made to stand-alone ERs since those claims are submitted in bulk by the affiliated hospital. Medicare generally pays more for services performed in an ER that in other settings.
MedPAC wants HHS to identify claims for all services provided at off-site ERs by using a modifier on claims.
Zach Gaumer, senior analyst for MedPAC has said that off-site ERs benefit from “a loophole” in the site-neutral law. The site-neutral law exempted stand-alone ERs to ensure access to care.
There 363 off-campus ERs affiliated with hospitals and about 200 independent ERs but those facilities can't bill Medicare unless they are teamed up with providers. MedPAC believes about 400 off-site ERs now are billing Medicare.
MedPAC members will formally vote on the modifier suggestion next month, but an informal vote Thursday indicated no commissioners objected to the idea.
Groups like the American Hospital Association and the Association of American Medical Colleges support the idea of a modifier as long as it's not too difficult to implement.
But both industry stakeholders and experts oppose the data being used to repeal the off-site ER exemption.
“I would caution throwing the baby out with the bathwater,” said Susan Feigin Harris, an attorney with Baker & Hostetler. “If we urge our institutions to create more community capacity, we cannot eliminate the financial or operational underpinnings needed to accomplish that policy.”
Emily Cook, a partner at McDermott Will & Emery said off-site ERs likely couldn't exist if they received the same rates as other off-site locations. Off-site ERs offer a limited set of services such as imaging, and lab services. They do not provide trauma care and they do not have operating rooms.
A study found that private insurers paid independent ERs 10 times more than urgent-care centers for the same services. It's not known how much Medicare spends on off-site ERs.