Wednesday, October 28, 2015

2015-10-27: House Legislation re Outpatient Center Definition and Payment

As of October 27, 2015 (pending vote in House).


11                       PARTMENTS OF A PROVIDER.

12          Section 1833(t) of the Social Security Act (42 U.S.C.

13  1395l(t)) is amended—

14                 (1) in paragraph  (1)(B)—

15                         (A) in clause (iii), by striking ‘‘but’’ at the

16                 end;

17                         (B) in clause (iv), by striking the period at

18                 the end and inserting ‘‘; and’’; and

19                         (C) by adding at the end the following new

20                 clause:

21                                ‘‘(v) does not include applicable items

22                         and  services (as  defined in  subparagraph

23                         (A) of paragraph  (21))  that  are  furnished

24                         on  or  after  January   1,  2017,  by an  off-

25                         campus  outpatient   department   of  a  pro-

3                 (2)  by  adding  at  the  end  the  following new

4          paragraph:

5                 ‘‘(21) SERVICES  FURNISHED   BY  AN   OFF-CAM-


7                         ‘‘(A) APPLICABLE  ITEMS AND  SERVICES.—

8                 For  purposes  of paragraph  (1)(B)(v)  and  this

9                 paragraph,  the term ‘applicable items and serv-

10                 ices’ means items and services other than emer-

11                 gency   department   services  (identified,   as   of

12                 January   1,  2015,  by  HCPCS   codes  99281–

13                 99285  (and  as  subsequently  modified  by  the

14                 Secretary)).

15                         ‘‘(B)  OFF-CAMPUS  OUTPATIENT   DEPART-

16                 MENT  OF  A PROVIDER.—

17                                ‘‘(i)  I GENERAL.—For  purposes  of

18                         paragraph   (1)(B)(v)  and  this  paragraph,

19                         subject to clause (ii), the term ‘off-campus

20                         outpatient    department    of    a     provider’

21                         means a department  of a provider (as  de-

22                         fined in section 413.65(a)(2)  of title 42 of

23                         the Code of Federal  Regulations, as in ef-

24                         fect as of the date of the enactment of this

25                         paragraph)  that  is not located—

2                                such   section  413.65(a)(2))   of   such

3                                provider; or

4                                        ‘‘(II)    within  the    distance   (de-

5                                scribed in such definition of campus)

6                                from a  remote  location of a  hospital

7                                facility  (as   defined  in  such  section

8                                413.65(a)(2)).

9                                ‘‘(ii)   EXCEPTION.—For     purposes of

10                         paragraph   (1)(B)(v)  and  this  paragraph,

11                         the   term   ‘off-campus  outpatient depart-

12                         ment of a provider’ shall not include a de-

13                         partment  of a provider (as so defined) that

14                         was billing under  this  subsection with re-

15                         spect  to  covered OPD  services  furnished

16                         prior  to the date  of the enactment  of this

17                         paragraph.

18                         ‘‘(C) AVAILABILITY   OF   PAYMENT  UNDER

19                 OTHER  PAYMENT  SYSTEMS.—Payments for ap-

20                 plicable items and services furnished by an off-

21                 campus  outpatient   department   of  a  provider

22                 that  are described in paragraph  (1)(B)(v)  shall

23                 be made under  the  applicable payment  system

24                 under  this  part   (other  than   under  this  sub-

1                 section)  if the  requirements  for  such  payment

2                 are otherwise met.

3                         ‘‘(D) INFORMATION NEEDED   FOR   IMPLE-

4                 MENTATION.—Each     hospital   shall  provide to

5                 the Secretary such information as the Secretary

6                 determines appropriate  to implement this para-

7                 graph  and paragraph  (1)(B)(v)  (which may in-

8                 clude  reporting   of  information  on  a  hospital

9                 claim using a code or modifier and reporting in-

10                 formation  about  off-campus outpatient  depart-

11                 ments of a provider on the enrollment form de-

12                 scribed in section 1866(j)).

13                         ‘‘(E) LIMITATIONS.—There shall be no ad-

14                 ministrative   or  judicial  review  under   section

15                 1869,  section  1878,  or  otherwise  of  the  fol-

16                 lowing:

17                                ‘‘(i) The determination of the applica-

18                         ble items and services under subparagraph

19                         (A) and applicable payment systems under

20                         subparagraph  (C).

21                                ‘‘(ii) The  determination  of whether a

22                         department  of a  provider meets  the  term

23                         described in subparagraph  (B).

1                                ‘‘(iii) Any information  that  hospitals

2                         are  required  to  report  pursuant   to  sub-

3                         paragraph  (D).’’.

Tuesday, October 6, 2015

How CMS defines MACs and Carriers for CLFS Policymaking

In a recent blog, I suggested that CMS rules should lead it to use "MACs" (Novitas, Noridian, etc) to calculate gapfill pricing medians, rather than using "states."   The relevant regulation is 42 CFR 414.508).   I stated in the simplest reading, the regulation leads to the unit of analysis as "carriers" not "states."  I also stated that "carriers are MACs."   CMS states similarly, in October 1, 2015 PAMA rulemaking.  At 80 Fed Reg 59410, CMS writes,

[W]e use
gapfilling when no comparable existing
test is available. We instruct each MAC
to determine a contractor-specific
amount for use in the first year the new
code is effective.

(We note that we are
proposing to replace ‘‘carrier’’ with
contractor to reflect that Medicare has
replaced fiscal intermediaries and
carriers with MACs.) are required to establish
contractor-specific amounts on or before
March 31. Contractors may revise their
payment amounts, if necessary, on or
before September 1, based on additional
information. After the first year, the
contractor-specific amounts are used to
calculate the NLA, which is the median
of the contractor-specific amounts,

The unit of function is "each MAC" which, where the text refers to MAC as singular, established "an amount," singular.  So unless, for example, CMS thinks New England has five or six MACs, it is instructing the New England "MAC" to set "a[n] amount."   To me the simplest reading is that each MAC (such as Palmetto, FCSO, etc) is a rate setting entity, so that there are about ten of them, not 57.  CMS does not routinely and ordinarily refer to having 57 MACs today, although there are 57 CLFS zones.

When the Gapfill regulation was originally promulgated, on December 1, 2006 (here), CMS discussed the process in the preamble (page 69703).  CMS states, "manual instructions are
provided to each Medicare carrier to determine a payment amount for its geographic area(s) for use in the first year, and the carrier-specific amounts are used to establish an NLA for following years."   Adding, "[T]here is also a specific time frame to perform this revision so that we have adequate
time to receive and use the carrier specific amounts for the calculation of the next year’s clinical laboratory fee schedule...we proposed to pay for a new gapfilled laboratory test under our existing methodology for the first year (the carrier would establish a gapfill amount.) Beginning in the second year, the test would be paid at the national limitation amount. This would result in consistent payment in geographic areas for a new test using the median of the carriers’ gapfilled amounts."  There is no specific definition of "median of the carriers" and the most natural definition would be an understanding of "carriers" as contractors or MACs, not as states or subsections of states under the old CLFS zones.