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Volume 14, Issue 3 Download for iPad


On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) issued the 2020 Physician Fee Schedule (PFS) Proposed Rule, and the 2020 Medicare Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule. In this issue, we will look at those proposals of most relevance to oncologists.


Conversion Factor

The Conversion Factor (CF) is the value in Medicare’s payment formula that turns Relative Value Units (RVUs) into dollar values. The CF is updated annually and published in the annual Physician Fee Schedule (PFS). For calendar year (CY) 2020, the estimated PFS CF is $36.09, up slightly from the CY 2019 PFS conversion factor of $36.04 due to a positive budget neutrality adjustment of 0.14%. This is based on the proposed PFS rule and may change slightly once the final rule comes out.

Payment Impact on PFS Services

Each year CMS includes the estimated impact of the proposed rule by specialty. Table 110 (CY 2020 PFS Estimated Impact on Total Allowed Charges by Specialty) of the proposed rule shows the payment impact on PFS services of the policies contained in the proposed rule: Hematology/Oncology 0%, Radiation Oncology 0% and Rheumatology 0%.

However, the actual impact on a specific practice is dependent on the types and number of services provided and may be higher or lower than that estimated by CMS.

Payment for Evaluation and Management (E/M) Services in CY 2020 and 2021

Payment for Care Management Services CY 2020

Transitional Care Management (TCM) Services (CPT codes 99495 and 99496) - CMS is proposing to increase payment for the care management services provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

  • 99495 (Moderate) – Increased work RVU from 2.11 to 2.36
  • 99496 (Complex) – Increased work RVU from 3.05 to 3.10

Chronic Care Management (CCM) Services - CMS is proposing new HCPCS G codes for certain CCM services, replacing some of the existing CCM codes with Medicare-specific codes to allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and to better distinguish complexity of illness as measured by time.

  • GCCC1 - Description: (Chronic care management services, initial 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and comprehensive care plan established, implemented, revised, or monitored. (Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately)). Additional 20 minutes of initial clinical staff time per month - estimated payment rate $42 (same as CPT 99490)

  • GCCC2 - Description: (Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure). (Use GCCC2 in conjunction with GCCC1). (Do not report GCCC1, GCCC2 in the same calendar month as GCCC3, GCCC4, 99491)).  Additional 20 minutes of clinical staff time per month – estimated payment rate $31.25

Principle Care Management (PCM) Services - CMS proposes to create new codes to pay clinicians for providing care management for patients with a single serious and high-risk condition:

  • GPPP1 - 30 minutes of physician time per month – one complex chronic condition (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.) Estimated Medicare payment rate: $74.24

  • GPPP2 - 30-minutes of clinical staff time per month – one complex chronic condition (Comprehensive care management for a single high-risk disease services, e.g., Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities). Estimated Medicare payment rate: $42.00

Evaluation & Management CY 2021

CMS is proposing revisions to the evaluation and management (E/M) documentation and payment policies that they finalized in the 2019 PFS Final Rule for CY 2021. In the 2019 PFS Final Rule, CMS finalized their proposal to collapse the payment rate for E/M codes and implement a single, blended payment rate for office visit levels 2 through 4 while maintaining the payment rate for the level 5 visit effective CY 2021.

In light of the E/M reporting and payment revisions made by CMS in the 2019 Final Rule, and CMS’ solicitation for suggestions on further reducing physician burden, the American Medical Association (AMA) established the joint AMA CPT Workgroup on E/M to develop an alternative approach.

The AMA CPT Editorial Panel undertook to revise the E/M office visit reporting guidelines with the following four primary objectives:

  1. To decrease administrative burden of documentation and coding.
  2. To decrease the need for audits, through the addition and expansion of key definitions and guidelines.
  3. To decrease unnecessary documentation in the medical record that is not needed for patient care.
  4. To ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties.

On February 9, 2019, the AMA CPT Editorial Panel approved revisions to the office or other outpatient services CPT E/M Codes (99201-99215). The AMA provides the following summary of revisions to these codes effective January 1, 2021.

AMA Summary of E/M Revisions

  1. Eliminate history and physical as elements for code section: While the physician’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.
    • The Workgroup revised the code descriptors to state providers should perform a “medically appropriate history and/or examination”

  2. Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time:
    • MDM: The Workgroup did not materially change the three current MDM sub-components but did provide extensive edits to the elements for code selection and revised/created numerous clarifying definitions in the E/M guidelines. (See below for additional discussion.)
    • Time: The definition of time is minimum time, not typical time, and represents total physician/qualified health care professional (QHP) time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. These definitions only apply when code selection is primarily based on time and not MDM.

  3. Modifications to the criteria for MDM: The Panel used the current CMS Table of Risk as a foundation for designing the revised required elements for MDM. Current CMS Contractor audit tools were also consulted to minimize disruption in MDM level criteria.
    • Removed ambiguous terms (e.g. “mild”) and defined previously ambiguous concepts (e.g. “acute or chronic illness with systemic symptoms”).
    • Also defined important terms, such as “Independent historian.”
    • Re-defined the data element to move away from simply adding up tasks to focusing on tasks that affect the management of the patient (e.g. independent interpretation of a test performed by another provider and/or discussion of test interpretation with an external physician/QHP).

  4. Deletion of CPT code 99201: The Panel agreed to eliminate 99201 as 99201 and 99202 are both straightforward MDM and only differentiated by history and exam elements.

  5. Creation of a shorter Prolonged Services code: The Panel created a shorter prolonged services code that would capture physician/QHP time in 15-minute increments. This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection.

In the 2020 proposed rule, CMS addresses the CPT Editorial Panel adopted revisions to the office/outpatient E/M code descriptors, prefatory language, and billing guidelines, noting that some of the AMA revisions parallel those they made in the 2019 final rule such as the choice of time or MDM, to select code level. Differences include the number of code levels retained, the times, and inclusion of all time spent on the day of the visit; and elimination of options such as the use of history and exam or time in combination with MDM, to select code level.

CMS cites the AMA’s belief that its approach will accomplish greater burden reduction, is more clinically intuitive and reflects the current practice of medicine and is more likely to be adopted by all payers than the policies CMS finalized for CY 2021.

In response, for CY 2021, CMS proposes to align E/M coding with changes laid out by the AMA CPT Editorial Panel for office/outpatient E/M visits.  The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients (eliminating the level 1 visit for new patients), revise the code definitions including the times and MDM, requires performance of history and exam only as medically appropriate and allows clinicians to choose the E/M visit level based on either MDM or time. 

CMS is also proposing to adopt the AMA RUC-recommended work and time values for the office/outpatient E/M visit codes for CY 2021, and to establish separate values for levels 2-4 office/outpatient E/M visits for both new and established patients (rather than the blended rate CMS finalized in the 2019 PFS Final Rule for CY 2021).

CMS proposes to delete HCPCS code GPRO1 (extended office/outpatient E/M time) and to adopt the new AMA add-on CPT code 99XXX (Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)).

In the CY 2019 final rule, CMS established two new add-on G-codes GPC1X and GCG0X. However, in light of the revised office/outpatient E/M code set and RUC recommended values for CY 2021, CMS is now proposing to simplify the coding by consolidating the two add-on codes into a single add-on code, deleting GCG0X, and revising the code descriptor for GPC1X to read: GPC1X (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).

In addition to the revised description, CMS is also proposing to value HCPCS code GPC1X at 100% of the work and time values for CPT code 90785 and proposing a work RVU of 0.33 and a physician time of 11 minutes. Further, CMS states that GPC1X could be billed as applicable with every level of office and outpatient E/M visit.

CMS states that the AMA RUC-recommended values would increase payment for office/outpatient E/M visits. Table 118 of the proposed rule lists the estimated specialty level impacts associated with CMS refinements to the RUC recommended values for the office/outpatient E/M code set and a separate payment for HCPCS add-on code GPC1X if implemented in 2020. The estimated impact is +12% for Hematology/Oncology, -4% for Radiation Oncology and +13% for Rheumatology. 

Physician Supervision Requirements for Physician Assistants (PAs)

CMS is proposing to revise current regulations at 42 C.F.R. §410.72, which require all PA services be rendered under a physician’s general supervision, and instead allow PAs to practice more broadly in accordance with state law and state scope of practice.  In the absence of state law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services. CMS notes that many states have changed their laws to allow PAs to practice more autonomously, and the CMS proposal would allow states the flexibility to develop requirements for PA services that are appropriate for their state.

Review and Verification of Medical Record Documentation

In response to CMS’ Patients Over Paperwork initiative request for information (RFI), CMS is proposing to change the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, nurses, students, or other members of the medical team.

If finalized, this would also apply to regulations for teaching physicians, physicians, PAs and ARPNs, adding flexibility for these clinicians in all settings.

Merit-based Incentive Payment System (MIPS)

Proposed changes to the MIPS performance threshold:

  • CMS is proposing to increase the performance threshold (the minimum number of points to avoid a negative payment adjustment) from 30 points in 2019 to 45 points in 2020 and 60 points in 2021.
  • CMS is proposing to increase the additional performance threshold for exceptional performance to 80 points in 2020 and to 85 points in 2021.

Proposed changes to the MIPS performance categories:

  • Reduce the Quality performance category weight to 40% in 2020, 35% in 2021, and 30% in 2022.
  • Increase the Cost performance category weight to 20% in 2020, 25% in 2021, and 30% in 2022.

For reporting year 2020 (2022 payment period), CMS proposes the following allocation of the 100 MIPS points available:

  • Quality 40%
  • Cost 20%
  • Promoting Interoperability 25%
  • Improvement Activities 15%

CMS is also soliciting comments and feedback on a proposed new MIPS framework called the MIPS Value Pathways (MVPs), that CMS says will decrease clinician burden and increase the value of performance data. For reporting in 2021, MVP would move MIPS from its current state, which requires providers to report on many measures across multiple performance categories, to a system in which providers would report on fewer measures and activities that are relevant to the population they are caring for, a specialty or medical condition.  

CMS defines four guiding principles they would use to define MVPs:

  1. MVPs should consist of limited sets of measures and activities that are meaningful to clinicians, which will reduce or eliminate clinician burden related to selection of measures and activities, simplify scoring, and lead to sufficient comparative data.
  2. MVPs should include measures and activities that would result in providing comparative performance data that is valuable to patients and caregivers in evaluating clinician performance and making choices about their care.
  3. MVPs should include measures that encourage performance improvements in high priority areas.
  4. MVPs should reduce barriers to APM participation by including measures that are part of APMs where feasible, and by linking cost and quality measurement.

CMS is requesting feedback on the identified guiding principles as well as the following questions:

  1. Pathways:
    What should be the structure and focus of the Pathways? What criteria should we use to select measures and activities?
  2. Participation:
    What policies are needed for small practices and multi-specialty practices? Should there be a choice of measures and activities within Pathways?
  3. Public Reporting:
    How should information be reported to patients? Should we move toward reporting at the individual clinician level?

For more details, CMS has an online MVP graphic that illustrates their vision for the MIPS future state and the facilitated movement to Alternative Payment Models (APMs): https://qpp-cm-prod-content.s3.amazonaws.com/uploads/587/MIPS%20Value%20Pathways%20Diagrams.zip.

Bundled Payments

CMS is soliciting comments on how bundled payments, such as establishing per-beneficiary payments for multiple services or condition-specific episodes of care, can be applied under the physician fee schedule. CMS cites the Oncology Care Model (OCM) as an example of an episode payment model, in which participating physician practices receive a per-beneficiary Monthly Enhanced Oncology Services payment for care management and care coordination surrounding chemotherapy administration to cancer patients. In the proposed rule, CMS states that they are seeking public comments on opportunities to expand the concept of bundling to recognize efficiencies among physicians’ services paid under the PFS and better align Medicare payment policies with CMS’ broader goal of achieving better care for patients, better health for communities, and lower costs through improvement in the health care system.


Proposed 2020 PFS Rule: https://www.federalregister.gov/documents/2019/08/14/2019-16041/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other

Proposed 2020 PFS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2020-payment-and-policy-changes-medicare-skilled-nursing-facilities-cms-1718-f .

Quality Payment Program Fact Sheet: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/594/2020%20QPP%20Proposed%20Rule%20Fact%20Sheet.pdf.

Genentech Access Solutions

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  • Affordability options such as the BioOncology Co Pay card and referrals to independent co pay assistance foundations who may be able to help with out of pocket costs.
  • Patient Resource Center who helps to resolve questions about support services and information about treatment and diagnosis.

Some of the specific services provided by Genentech Access Solutions for oncology patients and practices include:

  • Benefits Investigations for drug and infusion and benefits reverification support
  • Prior Authorization resources
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  • Resources for denials and appeals
  • Patient assistance options, including affordability options such as co pay card, and free medicine through Genentech Patient Foundation.

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Updates to OPPS Payment Rates

CMS is proposing to update OPPS payment rates by 2.7%. The proposed update is based on the projected hospital basket increase of 3.2% for inpatient services reimbursed under the Inpatient Prospective Payment System (IPPS), less the proposed multifactor productivity (MFP) adjustment of 0.5%. CMS anticipates the total payments to OPPS providers (including beneficiary cost-sharing and changes in enrollment, utilization and case mix), for CY 2020 would be approximately $79 billion, an increase of approximately $6 billion from CY 2019 payment estimates. Hospital outpatient departments (HOPDs) failing to meet quality-reporting requirements will continue to receive the statutory 2.0% reduction in payments for OPPS services.

Site Neutrality

The OPPS proposed rule includes several policies aimed at reducing payment between certain outpatient sites of service to encourage site neutrality and to control for unnecessary increases in the utilization of outpatient services.

In CY 2020, CMS will complete the two-year phase-in of the reduction in payment for the clinic visit services described by HCPCS code G0463 Hospital outpatient clinic visit for assessment and management of a patient furnished in excepted off-campus provider-based departments (PBDs) (on-campus PBDs and dedicated emergency departments are excluded from these payment cuts). These off-campus departments would be paid at a rate of 40% of the OPPS rate in 2020. CMS states that the reduction in payment is meant to control unnecessary increases in the volume of this service. In CY 2019, the first year of the phase-in, the payment rate for G0463 was reduced from $23 to $19 and would be further reduced to $9 in CY 2020 for an overall savings of $14 per clinic visit for Medicare beneficiaries. CMS estimates the policy would save $160 million for beneficiaries by lowering their copayments and save the Medicare program an estimated $650 million in 2020.

The American Hospital Association (AHA) and the Association of Medical Colleges are plaintiffs to a lawsuit legally challenging CMS’ authority to reduce payments for hospital outpatient services provided in off-campus provider-based departments grandfathered under the Bipartisan Budget Act of 2015. This legal challenge is pending.5

In addition, CMS also proposes to expand the number of procedures payable when furnished in either the ambulatory surgery centers or outpatient hospital departments, such as knee replacements (Total Knee Arthroplasty) and certain coronary intervention procedures. CMS says the proposed changes would give patients more choices on where to obtain care, improving beneficiary access and convenience and lowering out-of-pocket expenses.

Supervision of Outpatient Therapeutic Services

Outpatient Therapeutic Services in Hospital and Critical Access Hospitals (CAHs)

The CY 2018 OPPS/ASC final rule stated that direct supervision is required for hospital outpatient therapeutic services covered and paid by Medicare that are furnished in hospitals as well as in provider-based departments of hospitals. The CY 2018 rule also reinstated the enforcement instruction providing for the nonenforcement of the direct supervision requirement for hospital outpatient therapeutic services in CAHs and small rural hospitals (less than 100 beds) through the end of CY 2019.

CMS says the upcoming expiration of the nonenforcement instruction of the direct supervision requirement for CAHs and small rural hospitals prompted them to consider changing the supervision level for hospital outpatient therapeutic services for all hospitals and CAHs. CMS states their belief that the direct supervision requirement for these services places an additional burden on providers that reduces their flexibility to provide medical care. Furthermore, CMS notes that they are not aware of any supervision-related complaints from beneficiaries or providers during the years that the nonenforcement instruction has been in effect.

Therefore, in the 2020 proposed rule, CMS is proposing to change the level of supervision for hospital outpatient therapeutic services from direct supervision to general supervision for services furnished by all hospitals and CAHs. Under general supervision, the supervising physician need not be “immediately available to furnish assistance and direction throughout the performance of the procedure” but, instead, the service must be “under the physician’s overall direction and control.”

CMS will continue to consult with the Hospital Outpatient Payment (HOP) Panel on the appropriate supervision levels for hospital outpatient services. CMS will also retain the ability to consider a change to the supervision level of an individual hospital outpatient therapeutic service to a level of supervision that is more intensive than general supervision through notice and comment rulemaking. CMS is seeking public comments on this proposal and on whether specific types of services, such as chemotherapy administration or radiation therapy, should be excepted from this proposal.

Payment Methodology for 340B Drugs

Section 340B of the Public Health Service Act (340B) allows participating hospitals and other providers to purchase certain covered outpatient drugs at discounted prices from manufacturers. In the CY 2018 OPPS final rule, CMS finalized their proposal to reduce payment from ASP +6% to ASP minus 22.5% for certain separately payable drugs or biologicals acquired through the 340B Program by a hospital paid under the OPPS that is not excepted from the payment adjustment policy. In CY 2019, CMS expanded the policy to include the payment reduction of ASP minus 22.5% for 340B-acquired drugs and biologicals furnished in nonexcepted off-campus PBDs paid under the PFS.

The CY 2018 and 2019 OPPS payment policies for 340B-acquired drugs are the subject of ongoing litigation. CMS cites the conclusion of the United States District Court for the District of Columbia that the Secretary of the Health and Human Services (HHS) Department exceeded his statutory authority by adjusting the payment rates for these drugs. CMS says they have asked the district court to enter final judgement so CMS can appeal it.

In the meantime, for CY 2020, CMS proposes to continue payment for certain 340B-acquired drugs and biologicals at the rate of ASP minus 22.5% including when furnished in nonexcepted off-campus PBDs paid under the PFS. However, CMS is also seeking comments on alternative payment models in the event of an adverse ruling on the policy by the United States Court of Appeals. CMS is seeking comments on the appropriate OPPS payment rate for 340B-acquired drugs, and whether a rate of ASP+3% could be an appropriate remedial payment amount both for CY 2020 and for purposes of determining the remedy for CY 2018 and CY 2019 payments in the event of an adverse ruling on the 340B payment policy.

Proposed Payment Adjustment for Certain Cancer Hospitals 6

CMS proposes to continue to provide additional payments to cancer hospitals so that the cancer hospital's payment-to-cost ratio (PCR) after the additional payments is equal to the weighted average PCR for the other OPPS hospitals using the most recently submitted or settled cost report data.

Beginning CY 2018, Section 16002(b) of the 21st Century Cures Act requires the weighted average PCR be reduced by 1.0 percentage point. A proposed target of 0.89 would be used to determine the CY 2020 cancer hospital payment adjustment to be paid at cost report settlement. The proposed payment adjustment would be the additional payments needed to result in PCR equal to 0.89 for each cancer hospital.

Increasing Price Transparency

On June 24, 2019, President Trump signed Executive Order 13877, Improving Price and Quality Transparency in American Healthcare to Put Patients First. The stated goal of this executive order is to help patients make well-informed decisions about their health care, and to make available meaningful price and quality information so they can make informed decisions based on cost and quality.7

This executive order directs the Secretary of HHS to propose a rule requiring hospitals to publicly post, and regularly update, standard charge information, including charges and information based on negotiated rates and for common or shoppable items and services, in an easy-to-understand, consumer-friendly, and machine-readable format.  The Order further directs the Secretaries of HHS, the Treasury, and Labor propose rules to require healthcare providers, health insurance issuers, and self-insured group health plans to provide or facilitate access to information about expected out-of-pocket costs for items or services to patients before they receive care.

In accordance, CMS makes the following proposals for CY 2020:

Proposed Requirements for Making Public All Standard Charges for All Items and Services

CMS proposes that hospitals make public their standard charges (both gross charges and payer-specific negotiated charges) for all items and services online in a machine-readable format.

Proposed Requirements for Making Public Consumer-Friendly Standard Charges for a Limited Set of ‘Shoppable Services’

CMS proposes requirements for hospitals to make public standard charge data for a limited set of “shoppable services” the hospital provides in a form and manner that is more consumer‑friendly. CMS would define ‘shoppable service’ as a service that can be scheduled by a health care consumer in advance. Specifically, CMS proposes that hospitals would do the following:

  • Display payer-specific negotiated charges for at least 300 shoppable services, including 70 CMS-selected shoppable services and 230 hospital-selected shoppable services.  If a hospital does not provide one or more of the 70 CMS selected shoppable services, the hospital must select additional shoppable services such that the total number of shoppable services is at least 300.
  • Include charges for services that the hospital customarily provides in conjunction with the primary service that is identified by a common billing code (e.g. Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ Diagnosis-Related Group (DRG).
  • Make sure that the charge information is displayed prominently on a publicly available webpage, clearly identifies the hospital (or hospital location), easily accessible and without barriers, and searchable.
  • Update the information at least annually.

Proposals for Monitoring and Enforcement

CMS proposes regulations for monitoring and enforcement of hospitals’ compliance with these requirements including evaluating complaints made by individuals or entities to CMS, reviewing individuals’ or entities’ analysis of noncompliance, and auditing hospitals’ websites. If a hospital is determined to be noncompliant with one or more of the requirements to make public standard charges, CMS may assess a monetary penalty after providing a warning notice to the hospital, or after requesting a corrective action plan from the hospital if its noncompliance constitutes a material violation of one or more requirements.  If the hospital fails to respond to CMS’ request to submit a corrective action plan or comply with the requirements of a corrective action plan, CMS may impose a civil monetary penalty on the hospital not in excess of $300 per day and publicize the penalties on a CMS website. CMS would establish an appeal process for hospitals to request a hearing before an Administrative Law Judge (ALJ) of the civil monetary penalty.  Under this process, the Administrator of CMS, at his or her discretion, may review in whole or in part the ALJ’s decision.


Proposed 2020 OPPS Fact Sheet: www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

Proposed 2020 OPPS Rule: www.federalregister.gov/documents/2019/08/09/2019-16107/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical.

Executive Order 13877: www.whitehouse.gov/presidential-actions/executive-order-improving-price-quality-transparency-american-healthcare-put-patients-first/.

1 CMS.gov. PFS Federal Regulation Notices. CMS-1715-P.  www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Accessed July 29, 2019.

2 www.AMA-assn.org. AMA CPT Evaluation and Management. www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management. Accessed July 29, 2019.

3 Federal Register August 9, 2019. Medicare Program: Proposed Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Price Transparency of Hospital Standard Charges; Proposed Revisions of Organ Procurement Organizations Conditions of Coverage; Proposed Prior Authorization Process and Requirements for Certain Covered Outpatient Department Services; Potential Changes to the Laboratory Date of Service Policy; Proposed Changes to Grandfathered Children's Hospitals-Within-Hospitals. Accessed August 9, 2019.

4 www.cms.gov. CMS Press Release CMS Takes Bold Action to Implement Key Elements of President Trump’s Executive Order to Empower Patients with Price Transparency and Increase Competition to Lower Costs for Medicare Beneficiaries. www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price. Accessed July 30, 2019.

5 AHA.org. American Hospital Association. Litigation – Site Neutral Payment Policy. www.aha.org/legal/litigation. Accessed August 24, 2019.

6 www.govinfo.gov. U.S. Government Publishing Office.  21st Century Cures Act.
www.govinfo.gov/content/pkg/PLAW-114publ255/html/PLAW-114publ255.htm. Accessed August 18, 2019.

7 Federal Register June 27, 2019. Improving Price and Quality Transparency in American Healthcare to Put Patients First. www.federalregister.gov/documents/2019/06/27/2019-13945/improving-price-and-quality-transparency-in-american-healthcare-to-put-patients-first. Accessed August 18, 2019.

Published by Rise Marie Cleland.Sponsored by Lilly Oncology

Risė Marie Cleland Rise@Oplinc.com

Oplinc, Inc.
1325 Officers Row
Suite A
Vancouver, WA 98661
360.695.1608 office

Comments and suggestions for future issues are welcome, please forward correspondence to Risė Marie Cleland by email at: Rise@Oplinc.com

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Risė Marie Cleland is the Founder and CEO of Oplinc, Inc., a national organization of oncology professionals. Through Oplinc, Inc., Ms. Cleland publishes the weekly Oplinc Fast Facts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.

Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.gov.

CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2019 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Copyright ©2019 Oplinc, Inc.

Oplinc, Inc., grants permission to distribute this newsletter without prior permission provided it is forwarded unedited and in its entirety.

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