All Entries Tagged With: "outliers"
More on the OPPS proposed rule
Earlier this week, I discussed the physician supervision provisions of the CY2010 OPPS proposed rule.
Another section of interest to many providers will be the sections on the new cardiac rehab, intensive cardiac rehab and pulmonary rehab benefits. CMS discusses their implementation of these new benefits added to the Social Security Act by the MIPPA, effective January 1, 2010. Of particular interest is CMS implementation of the MIPPA provision that states that physician supervision for these programs is assumed when provided in a hospital.
Other significant proposals in the rule include a large proposed increase in the OPPS outlier threshold from $1800 to $2,225, the highest the fixed dollar threshold has been since its introduction.
Additionally, a significant portion of the rule was also devoted to payment methodologies for drugs, however, the end resultant proposal for most drugs remains at ASP + 4%. This includes ASP based payment for therapeutic radiopharmaceutical when the statutory cost based payment methodology expires in 2009. CMS did make the submission of ASP data for therapeutic radiopharmaceutical voluntary, and will base rates on CY2008 hospital mean cost data if ASP is not available.
Similarly, brachytherapy sources, which also were under a statutory cost based payment methodology for 2009, will be transitioned to CY2008 hospital mean cost data (the usual method for setting APC rates for other services). CMS is soliciting comments on several of their proposals and I would encourage pharmacy, radiology and chargemaster coordinators to review these proposals carefully and submit comments if they disagree with any of the proposals.
OPPS outlier reconciliation and recoupment starts in 2009
This week, the OIG published the fiscal year 2007 annual report for the Health Care Fraud and Abuse Control Program. It reported $1.8 billion dollars in judgments and settlements for the year, with $797 million returned to the Medicare Trust Fund. The largest settlement for a hospital was related to outliers. A New Jersey hospital paid $7.5 million and signed a corporate integrity agreement for purposely inflating charges for inpatient and outpatient care between 1998 and 2003 to make the cases appear more costly and receive outlier payments to which it was not otherwise entitled.
This highlights one of the changes to the OPPS this year. Outpatient outliers will be reconciled in the same manner that inpatient outliers are reconciled. CMS implemented the reconciliation as a way to eliminate vulnerability to the outlier system similar to that shown in the case above. [more]
