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

Invisible Algorithms: The Hidden Role of Artificial Intelligence in USCIS Immigration Processing

February 10, 2026The Department of Homeland Security has confirmed that artificial intelligence and machine learning tools are now integrated into numerous operational functions within U.S. Citizenship and Immigration Services (USCIS). These tools are described as mechanisms to improve efficiency, reduce backlogs, and assist officers in managing an unprecedented volume of applications. DHS emphasizes that human adjudicators retain decision-making authority and that AI systems do not independently grant or deny immigration benefits. Find out how AI affects the U.S. immigration process.Client Alert

OAAPN | Year In Review: 2026 Ohio Board of Nursing and Ohio Law Rules

February 9, 2026Find out key changes to Ohio law and the Ohio Board of Nursing rules that have directly impacted APRN practice over the past year, including Psychiatric Inpatient Documents, Intimate Examinations, Signature Authority, Duties Related to Fetal Death, Retail IV Therapy Clinics, Release from Permanent Restrictions, Disciplinary Action, Course on Drugs and Prescriptive Authority, Overdose Reversal Drugs, Office Based Opioid Treatment, Withdrawal Management for Substance Use Disorder, Safe Haven Program, and more.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.
Older posts
Newer posts