Resources

Client Alerts, News Articles, Blog Posts, & Multimedia

Everything you need to know about BMD and the industry.

CMS to Once Again Reprocess Outpatient Clinic Claims

Client Alert
November 11, 2021

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.

Healthcare and Hospital LawAmanda L. Waesch
Client Alert

Ohio House Bill 537: Proposed Regulations for Midwives and Birthing Centers

January 28, 2026House Bill 537, introduced in the Ohio House of Representatives, proposes a comprehensive regulatory framework for certified nurse-midwives, certified midwives, licensed midwives, and traditional midwives. The legislation would clarify scope of practice, establish licensure standards, and impose new requirements for freestanding birthing centers and home births. Healthcare providers and facilities should be aware of the proposed changes and their potential operational impact.Client Alert

Proposed Health Information Privacy Reform Act Expands Protections Beyond HIPAA

January 26, 2026The Health Information Privacy Reform Act (HIPRA) seeks to extend privacy protections to health data not covered under HIPAA, including data collected by apps and wearables. HIPRA introduces broader definitions of protected health information, strengthens privacy and security requirements, establishes patient notification rights, and sets national de-identification standards. Companies processing health data should monitor developments to ensure compliance.Client Alert

Medicare Updates on Skin Substitutes: LCDs Withdrawn, Payment Changes Take Effect

January 23, 2026Medicare’s planned Final Local Coverage Determinations (LCDs) for skin substitutes were withdrawn in late December 2025, meaning previous coverage rules remain in effect. The 2026 Medicare Physician Fee Schedule introduces a single payment rate of approximately $127.14 for these products. Providers should review implications for diabetic foot and venous leg ulcer treatments.Client Alert

Understanding the Seven Core Elements of an Effective Healthcare Compliance Program

January 22, 2026The Affordable Care Act requires healthcare providers participating in Medicare, Medicaid, and CHIP to maintain an effective compliance program. Guidance from the Department of Health and Human Services and the Office of Inspector General outlines seven core elements that form the foundation of these programs, from written policies and compliance oversight to auditing, training, and corrective action. This alert highlights each element and explains how practices can tailor compliance programs to their size and risk profile while meeting federal expectations.Client Alert

Preventing a Board Investigation

January 21, 2026Healthcare professionals in Ohio are subject to licensing board investigations that can lead to disciplinary action. Staying compliant with regulations, documenting carefully, and operating within your professional scope can help prevent issues. If contacted by a board, working with an attorney is critical to protect your license and rights.
Older posts
Newer posts