November 10, 2023
Top Highlights from CMS’ 2024 OPPS Final Rule
Last week, CMS released the 2024 Medicare Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rule. In this rule, CMS finalized an increase in payment rates under OPPS by 3.1% for 2024, new price transparency requirements and changes to the quality programs. The Agency is not finalizing proposals regarding the re-adoption of the Hospital Outpatient /ASC facility volume data on selected outpatient surgical procedures measure nor the removal of the Left Without Being Seen measure from the OQR program. CMS previously sought comments on establishing additional payments to hospitals for maintaining access to essential medicines but decided it will instead pursue changes to the conditions of participation in future rules to achieve pharmaceutical supply chain resiliency.
CMS finalized a number of payment updates to the OPPS, ASC, and 340B programs:
- Under OPPS, the final rule increases payment rates by 3.1% for 2024.
- For ASCs, the rule will continue applying the productivity-adjusted hospital market basket update to the ASC payment system through 2025. CMS initiated this trial policy in 2019 with the intention of running it through 2023; however, citing the impact the COVID-19 public health emergency had on health care utilization, CMS is continuing this policy to provide additional time for analysis.
- CMS also finalized its proposal to pay Average Sales Price (ASP) plus 6% for 340B-acquired drugs and biologicals for 2024. In a separate rule released last week, CMS finalized its proposal to repay about $9 billion in a lump-sum payment to roughly 1,700 340B hospitals that were unlawfully underpaid between 2018 through 2022. To help offset the lump-sum payment, CMS also finalized a proposal to recoup roughly $7.8 billion by adjusting the OPPS conversion factor by minus 0.5% beginning in CY 2026 and continuing for about 16 years, until the full $7.8 billion is recouped.
Hospital Price Transparency
CMS finalized many new requirements related to Hospital Price Transparency (HPT) and changes to the enforcement process. These changes include:
- Standardization of the data and formatting of the required Machine-Readable Files (MRFs).
- Accessibility requirements for the MRF on the hospital’s website.
- Requiring affirmation within the MRF that it is true, accurate and complete with certification from an authorized hospital official.
- Strengthened and streamlined enforcement capabilities such as:
- Publishing all enforcement activities on price transparency, including warning notices, on a public CMS website. Currently, information is only published if the hospital is given a Civil Monetary Penalty.
- Requiring hospitals to acknowledge receipt of an agency’s non-compliance warning notice by submitting an acknowledgement of the warning notice to CMS.
Whilst the rule largely finalizes changes as proposed, CMS decided to change the enforcement dates; rather than enforcing all changes at one time, CMS will enforce the changes through a phased-in approach. To read more about the new HPT requirements, click here to access the CMS Fact Sheet regarding HPT.
Mental and Behavioral Health
CMS finalized its proposal to establish the Intensive Outpatient Program (IOP) under Medicare, and respective payments for services provided in Hospital Outpatient Departments (HOPDs), Community Mental Health Centers (CMHCs), Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs). CMS also finalized a weekly payment adjustment for IOP services provided by opioid treatment programs. Under IOP, physicians will need to certify medical necessity at least every other month.
CMS finalized several changes to the hospital Outpatient Quality Reporting (OQR) and ASC Quality Reporting (ASCQR) programs:
- COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) measure to align with the updated Centers for Disease Control and Prevention (CDC) clinical guidelines.
- Cataracts: Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery measure, to require use of one of three specific survey instruments to measure change in visual function pre-and post-operatively to further standardize data collection and reduce facility burden.
- The Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients measure, to align with updated clinical guidelines.
Newly adopted measures:
- Risk-Standardized Patient-Reported Outcomes Following Elective Primary Total Hip and/or Total Knee Arthroplasty, with modification to extend the voluntary reporting period to a total of three years prior to requiring mandatory reporting beginning with the CY 2028 reporting period and CY 2031 payment determination.
- For the OQR program only, Hospital OQR program the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults electronic clinical quality measure (eCQM), with modification to extend the voluntary reporting period to a total of two years prior to requiring mandatory reporting beginning with the CY 2027 reporting period.