Key Takeaways from CMS Proposed Rule 2019 (1) - PowerPoint PPT Presentation

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Key Takeaways from CMS Proposed Rule 2019 (1)

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Recently CMS issued the proposed rules for 2019 Outpatient Prospective Payment System and Medicare Physician Fee Schedule. Both of these rules have significant reimbursement changes. However; these changes are yet to be finalized. – PowerPoint PPT presentation

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Title: Key Takeaways from CMS Proposed Rule 2019 (1)


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  • Key Takeaways from CMS Proposed Rule 2019

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Key Takeaways from CMS Proposed Rule 2019
Recently CMS issued the proposed rules for 2019
Outpatient Prospective Payment System and
Medicare Physician Fee Schedule. Both of these
rules have significant reimbursement changes.
However these changes are yet to be
finalized. The key takeaways from CMS proposed
rule mentions There will be a single payment
rate for Level 2-5 ( Evaluation and Management
visits) CMS proposes a single rate that would
apply to all Level 2 through Level 5 visits for
new and established patients. New patient visits
would be reimbursed at a rate of 135 for Level
2-5 visits established patient visits would be
reimbursed at a rate of 93. With this new
payment practice the providers will see a
significant rise in the reimbursement rates which
will be about 79 to 81 hike for the Level 2
visits. Under the existing structure, Level 4
and Level 5 visits for new patients are
reimbursed respectively at rates of 167 and 211.
Medical Billing Services in Oregon
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Key Takeaways from CMS Proposed Rule 2019
  • Reduced payment for clinic visits
  • CMS would extend site neutrality beyond that
    approved by Congress in Section 603 of the
    Bipartisan Budget Act. This proposal arguably
    exceeds CMS rulemaking authority.
  • CMS proposes to increase the present non-excepted
    off-campus PBD reimbursement diminutions to all
    off-campus PBDs.
  • As a result, all evaluation and management
    clinical visits at off-campus PBDs will be
    receiving 42 of the OPPS reimbursement. For
    example, the OPPS payment for a clinic visit is
    approximately 116 payment under the new PFS
    equivalent rates would be approximately 46. For
    most PBDs, clinical reimbursement is the main
    source of revenue.
  • Limitations of the expansion at grandfathered
    off-campus provider-based departments
  • CMS seeks to revise the capability of
    grandfathered PBDs receiving OPPS reimbursement
    to increase their service lines.
  • Under the proposed rule CMS is looking forward to
    limiting the services which were earlier
    reimbursed under the OPPS. Now it will be
    reimbursed who meets the clinical families of the
    services test.

Medical Billing Services in Oregon
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Key Takeaways from CMS Proposed Rule 2019
Any of these services which dont meet the test
requirements will be reimbursed underneath the
lower PFS-equivalent rate, a reduction of
approximately 61. Expansion of 340B payment
cuts In the proposed rule CMS anticipates
increasing these cuts to all 340B drugs provided
at non-excepted off-campus PBDs. Therefore, the
child sites which joined under the 340B Program
as DSHs, RRCs, or urban SCHs now will be
subjected to a 27 reduction from the start of
this January month. Reduced Medicare Part B drug
reimbursement CMS proposes to cut WAC
reimbursement rates to WAC plus 3, beginning in
January 2019. While the stated intent of these
cuts is to lower overall drug costs to
beneficiaries, this action is more likely to lead
to price increases for most manufacturers new
drugs in order to match the reimbursement rates
of competitors.
Medical Billing Services in Oregon
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