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CMS Releases OPPS Final Rule

Michelle A. Leppert, CPC-A, for HCPro, November 3, 2011

Under that proposal, hospitals would have received lower payment for outpatient CRT-D procedures compared to what they would have received if CMS had based payment on outpatient claims data, Shah says.

"Historically we haven't seen CMS crossing payment systems in determining payment policy even when providers have asked CMS to create parity, for example between drug reimbursement in the physician office and hospital setting," Shah says. CMS received numerous comments from the industry indicating that its proposal was not appropriate and that it should not be implemented. 

As a result of comments received and CMS' own further analyses, the agency decided not to finalize its proposal for CY 2012. Instead CMS indicated it believes looking across payment system to set payment rates is  within its scope and will consider this appropriate in the future. "At the end of the day, I think CMS realized that its proposal was simply not inappropriate for implementation at this time," Shah says. As a result, the CRT-D rate set by Medicare in the outpatient setting for CY 2012 is based on outpatient claims data only and will be much higher than what CMS had originally proposed. This is another victory for outpatient providers, Shah says.

Drug payment changes

Providers received more good news with respect to drug payments. First, CMS proposed increasing the drug packaging threshold to $80, but reduced that to $75 in the final rule.

Second, and perhaps more importantly, CMS recognized that it has a flaw in its separately payable drug reimbursement calculation methodology, Shah says. CMS' proposed average sales price (ASP) plus percentage typically drops by one percentage point from the proposed rule to the final rule. CMS proposed ASP+4%, but it was expected to drop to ASP+3% in the final rule due to the use of more complete claims and cost data, Shah says. This has happened in previous years as well and this year CMS examined this issue by conducting additional analyses during the comment process.

"I think CMS deserves kudos here for taking on the analytical question of why the ASP plus percentage has dropped each of the past three years from the proposal to the final rule and for conducting analysis to really understand what's going on," Shah says.

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