Adjustment on Payments for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments

The American Hospital Association challenged CMS’ use of its authority under Subsection (t)(2)(F) of the Medicare statute to pay for certain outpatient clinic visit services provided at excepted off-campus Provider-Based Departments (PBDs) at the same rate that CMS uses to pay non-excepted off-campus PBDs for those services under the separate Physician Fee Schedule as finalized with Final Rule, Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting, 83 Fed. Reg. 58,818 (11/21/2018) (Rule).

The United States District Court for the District of Columbia issued instructions for CMS to immediately cease the clinic visit provided at excepted off-campus PBDs payment reduction for CY 2019 implemented with final Rule, Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting, 83 Fed. Reg. 58,818 (11/21/2018) (Rule).

CMS installed a revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines. This revised Pricer went into production on 11/4/2019 and applies to claims with a line item date of service of 1/1/2019 through 12/31/2019. On or before 3/1/2020, and over the next few months, the MACs will automatically reprocess claims paid at the reduced rate; no provider action needed. Providers do not need to call National Government Services to request the adjustment, nor is it necessary to request a redetermination or reopening to correct these claims. Claims processed after the pricer was installed on 11/4/2019 are processed appropriately.

Posted 2/7/2020