UPH Government & External Affairs

Outpatient Prospective Payment System (OPPS) Final Rule

by | Dec 17, 2020

On December 2, the Centers for Medicare & Medicaid Services (CMS) released the Outpatient Prospective Payment System (OPPS) 2021 Final Rule, which is the annual rule related to outpatient hospital departments and other outpatient facilities. The UnityPoint Health Government & External Affairs team has been actively monitoring this rule and, during the public comment period, submitted a formal comment letter reflecting feedback from leadership and content experts. Key provisions of this final rule are below.

340B Drug Pricing Program

Recently, the OPPS rule has eroded 340B program payments to covered hospitals. In this year’s final rule, the current 2020 payment policy was maintained for 2021. Specifically, the payment rate of Average Sales Price (ASP) minus 22.5% for 340B acquired drugs remains, instead of the proposal to further reduce the rate to ASP minus 28.7%. UnityPoint Health is continuing to work with 340B Health and the American Hospital Association (AHA) to demonstrate the value of this program to our communities, elected officials and agency administrators.

Site Neutral Policies

To promote value, an overarching CMS strategy has been to neutralize reimbursement across sites of care. While UnityPoint Health supports value-based care, the health system also wants to assure safety for its patients and the financial sustainability of hospitals who deliver care to the most acute and complex patients.

  • Off-Campus Provider-Based Departments: The 40% PFS-equivalent rate for a clinic visit service (HCPCS code G0463) was retained for CY 2021. UnityPoint Health has been advocating for the restoration of the former reimbursement level in recognition of the acuity/complexity of patients served and the heightened accreditation and licensing requirements for hospital-based clinics.

  • Inpatient Only (IPO) List: This rule starts the process of eliminating the IPO list over the course of three years beginning with the removal of 298 musculoskeletal-related services in 2021. UnityPoint Health is opposed to the complete elimination of the IPO list. Without a more targeted review, the health system believes potential patient safety issues receive inadequate attention and, overall, is concerned this (1) encourages more infrastructure builds to cater to younger, healthier and less costly patients, (2) diverts resources from existing inpatient settings, and (3) leads to greater health care costs.

  • ASC Covered Procedure List (CPL): CMS drastically changed this process between the public comment period and the final rule release. The new process permits additions to CPL for procedures designated as a covered surgical procedure. Using this new process, instead of the proposed addition of 11 procedures, including total hip arthroplasty (THA), this rule adds 278 procedures to the CPL. UnityPoint Health expressed concern about loosening the criteria for CPL inclusion and, since THA was only removed from the IPO list in 2019, requested CMS review more data prior to its addition on CPL.

Level of Supervision for Outpatient Therapeutic Services

Starting January 1, 2021, CMS established general supervision as the minimum required supervision level for all non-surgical extended duration therapeutic services (NSEDTS). Additionally, direct supervision may include virtual presence of the physician through audio/video real-time communications technology subject to the clinical judgment of the supervising physician until the end of the year in which the PHE ends or December 31, 2021, whichever is later. UnityPoint Health supported these changes.

Prior Authorization

Effective July 1, 2021, CMS finalized the addition of two new service categories: Cervical Fusion with Disc Removal (CPT codes 22551 & 22552); and Implanted Spinal Neurostimulators (CPT codes 63650 & 63685). UnityPoint Health was aligned with AHA in opposing the prior authorization processes without a showing they were aimed at “controlling unnecessary increases in the volume of covered OPD services.”

Hospital Star Ratings

CMS implemented numerous changes to the rating system aimed to simplify the methodology, improve predictability and enhance comparability. The rule finalized many suggestions from UnityPoint Health, including streamlining domains, replacing the latent variable model, and moving to a peer groups rating concept. Overall, CMS estimates that star ratings will be more normalized, with shifts to more 3- and 4-star ratings. UnityPoint Health has operational questions left unanswered by the final rule and will continue to monitor this program.

Further information from CMS on this Final Rule: