CMS Proposes PPC Medicaid Payment Reductions
CMS explains that HCACs would set a floor on the payment reductions. States seeking to reduce payment by specifying diagnosis codes as OPPCs—above and beyond the HCAC category—would have to adhere to the following guidelines:
- The codes must have a high cost or high volume, or both
- The codes must result in the assignment of a case to a MS-DRG that has a higher payment when the code is present as a secondary diagnosis.
- The codes must describe conditions that could reasonably have been prevented through the application of evidence-based guidelines
The proposed rule, if finalized, would have varying effects on Medicaid providers—already 21 states have programs in place to reduce Medicaid payment for specified conditions. So Medicaid providers in the remaining 29 states would face new payment reductions as a result of the rule. States that already have payment reduction programs in place vary considerably regarding their defined PPCs.
Mackaman encourages providers to read and comment on the proposed rule. She encourages Medicaid providers in states that already have payment reduction programs in place to examine the current programs and consider how their states might expand the reductions to other settings. Providers in states that currently lack such a program may want to examine nearby state programs, as well as how such measures will affect them.
CMS’ proposed rule will be published in the February 17 Federal Register, available online.
Mike Iarrobino is Managing Editor of HCPro's MedicareFind, a comprehensive database of Medicare rules, regulations, and CMS documents governing reimbursement.
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