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CMS to Once Again Reprocess Outpatient Clinic Claims

Overview:

The Hospital Outpatient Prospective Payment System (OPPS) Rule was passed in November 2018, which was intended to prevent the Centers for Medicare and Medicaid Services (CMS) from paying more for services rendered in outpatient settings than what they paid for the same services rendered in physician offices that are simply owned by hospitals or health systems.[1]

The Rule set payment rates for these services at “excepted” off-campus provider-based departments (those facilities that were excepted from reimbursement reductions under the Bipartisan Budget Act of 2015) at the same rate for non-excepted provider-based departments (PBDs) pursuant to the Physician Fee Schedule (PFS). However, in 2019, the reimbursement rate for services at these excepted facilities was set at 70%, and in 2020, just 40%.[2]  

The American Hospital Association (AHA) then sued CMS in the U.S. District Court for the District of Columbia in 2019 over the reimbursement reductions, and the Court ruled in favor of the AHA. As a result of the decision, CMS reprocessed the 2019 claims at the full 100% rate.[3]

Reprocessing Claims:

In 2020, however, the U.S. Court of Appeals for the D.C. Circuit reversed the district court’s decision. Pursuant to the reversal, starting November 1, 2021, CMS will once again begin reprocessing claims at excepted PBDs for outpatient claims to ensure that the services are reimbursed at the 70% rate for services rendered between January 1, 2019, and December 31, 2019.[4]

Conclusion:

As a result, excepted PBD providers will now have to refund the difference in coinsurance either to patients or insurers who paid an increased amount in cost-sharing when reimbursement was set at 100%, to reflect the reduction.[5]

CMS notes that providers do not need to take any other action as they reprocess claims.[6]  But providers should be aware of this reprocessing.

If you have any questions about how reprocessing will work or questions regarding issuing refunds, please contact Healthcare and Hospital Law Member Amanda Waesch at alwaesch@bmdllc.com. Special thanks to Rachel Stermer for her assistance in this client alert.

[1] CMS, Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments: Payment Update, (Sept. 9, 2021) https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2021-09-09-mlnc#_Toc82072549.

[2] Id.

[3] Id.

[4] Id.

[5] Id.

[6] Id.

Protections Under Federal and Ohio Law for Bona Fide Prospective Purchasers of Contaminated Property

Most industrial/commercial property developers are generally aware of the Comprehensive Environmental Response, Compensation, and Liability Act (“CERCLA”), often also referred to as “Superfund”. CERCLA, a United Stated federal law administered by the U.S. Environmental Protection Agency, was created, in part, because the U.S. Environmental Protection Agency recognized that environmental cleanup could help promote reuse or redevelopment of contaminated, potentially contaminated, and formerly contaminated properties, helping revitalize communities that may have been adversely affected by the presence of the contaminated properties. Commercial property developers should be aware that CERCLA provides for some important liability limitations for landowners that own contaminated property impacted by materials hazardous to the environment. It can also assist with landowners concerned about the potential liabilities stemming from the presence of contamination to which they have not contributed. In particular, CERCLA provides important liability limitations for landowners that qualify as (1) bona fide prospective purchasers (BFPPS), (2) contiguous property owners, or (3) innocent landowners.

Puerto Rico Is Open For Business

Puerto Rico has the highest vaccination in the nation. More than 73% of the total population is fully vaccinated. The U.S. national average is just over 57%. The ports opened in June 2020 and San Juan held it first live concert this past summer. It is important to remember that Puerto Rico is a U.S. territory and there is no need for visas, the banking systems is almost identical to the mainland and the Island uses the U.S. postal service and U.S. dollar as its currency. There are thousands of flights from the U.S. to Puerto Rico daily and all main airlines fly to the Island.

Ohio Medical Board Changes Telemedicine Rules

A SCMS News Article by Scott Sandrock.

The Rising Threat from Insiders – Get Your House in Order

As its name implies, an ‘Insider Threat’ originates inside an organization. An ‘insider’ is any person who has or had authorized access to or knowledge of an organization’s resources, including personnel, facilities, information, equipment, networks, and systems. ‘Insider threat’ can manifest from malicious, complacent, negligent or unintentional acts that negatively affect the integrity, confidentiality, and availability of the organization, its data, personnel, or facilities. Certainly, ‘Insider Threat’ can be an activity by a bad actor employee, but can also arise from an inadvertent or unknowing action inside an organization (such as an employee who unintentionally opens a phishing email or clicks on a malicious link).

In Cybersecurity– A Good Offense is the Best Defense

2021 has been a watershed moment for cybersecurity incidents as cybercrime has become a frequent headline and cyber criminals have thrived on unsuspecting and/or unprepared businesses and institutions. For example, the Solar Winds attack exposed sensitive data from top companies like Microsoft as well government agencies[1] and the Colonial Pipeline attack substantially disrupted the petroleum supply chain[2]. We have seen an almost 20% increase in data breaches and attacks since last year.