OPPS Proposed Rule Aims to Improve Healthcare

OPPS Proposed Rule Aims to Improve Healthcare

Today, I’d like to discuss the recently proposed policies by the Centers for Medicare & Medicaid Services (CMS) under the U.S. Department of Health and Human Services (HHS).

These proposals are part of the Calendar Year (CY) 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule and touch on a range of important updates aimed at improving healthcare delivery and addressing significant issues within our healthcare system.

  1. Payment Rate Updates: CMS proposes a 2.6 percent increase in OPPS payment rates for hospitals that meet quality reporting requirements. This adjustment is based on a projected hospital market basket percentage increase of 3.0 percent, reduced by a 0.4 percentage point productivity adjustment. The same update factor is proposed for ASC rates for an additional two years, ensuring these facilities also see a necessary increase in funding.
  1. Behavioral Health and Substance Use Disorder Services: To address the ongoing mental health crisis, CMS plans to maintain the current rate structure for Intensive Outpatient Program (IOP) services and Partial Hospitalization Program (PHP) services. These programs offer structured outpatient psychiatric care as an alternative to inpatient treatment, crucial for individuals with acute mental illness or substance use disorders.
  1. Access to Non-Opioid Pain Treatments: In a bid to combat the opioid crisis, CMS proposes additional payments for certain non-opioid treatments for pain relief in hospital outpatient and ASC settings from Jan. 1, 2025, through Dec. 31, 2027.
    This measure aims to provide safer pain management options for patients, reducing reliance on opioids.
  1. Payment for Remote Services: Recognizing the importance of telehealth, CMS is clarifying OPPS payment for services provided remotely by hospital staff. This includes aligning these requirements with Medicare telehealth services, which have become essential during the pandemic and continue to offer significant benefits in improving access to care.
  1. Support for Indian Health Services (IHS) and Tribal Facilities:To better support healthcare delivery in underserved areas, CMS proposes an add-on payment for high-cost drugs provided by IHS and tribal hospitals. This initiative aims to address the unique financial challenges faced by these facilities and improve service delivery to these communities.
  1. Specialized Diagnostic Radiopharmaceuticals: CMS plans to refine payment policies for high-cost diagnostic radiopharmaceuticals. The goal is to ensure accurate payment and access to essential nuclear medicine tests, thereby improving diagnostic capabilities and patient outcomes.
  1. Health Equity Measures: A significant focus of the proposed rule is advancing health equity. CMS is introducing new measures for hospitals, rural emergency hospitals, and ASCs to screen for social determinants of health (SDOH). Hospitals and ASCs that do not meet these health equity standards, which include screening for SDOH, will face a 2 percent reduction in annual payment updates.
  1. Maternal Health Initiatives: Addressing the maternal health crisis in the United States, CMS proposes baseline health and safety requirements for hospitals and critical access hospitals for obstetrical services. These standards cover organization, staffing, delivery of care within obstetrical units, emergency services readiness, transfer protocols for obstetrical patients, and annual staff training on evidence-based maternal health practices and cultural competencies. These measures are crucial for reducing maternal mortality and morbidity, which disproportionately affect underserved communities.
  1. Medicare Physician Fee Schedule (PFS) Changes: The proposed CY 2025 Medicare Physician Fee Schedule (PFS) includes a 2.8 percent reduction in the conversion factor, impacting reimbursement rates. CMS also proposes measures to improve payment for and access to behavioral health services, extend certain telehealth waivers, and introduce new Merit-based Incentive Payment System (MIPS) Value Pathways.

These proposed changes are part of a broader effort by the Biden Administration to address healthcare disparities, expand access to care, and improve health outcomes across the country. The rule is currently open for public comment until Sept. 9, 2024. Your input and feedback are crucial during this period, as they will help ensure these policies are effective and equitable.

Programming note:

Listen to Angela Comfort report this story live today on Talk Ten Tuesday, 10 Eastern, with Chuck Buck and Dr. Erica Remer.

Facebook
Twitter
LinkedIn

Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P

Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, serves as the Assistant Vice President of Revenue Integrity at Montefiore Medical Center in New York. With over 30 years of extensive experience in Health Information Management operations, coding, clinical documentation integrity, and quality, Angela has established herself as a leader in the field. Before her tenure at Montefiore, she held the position of Assistant Vice President of HIM Operations at Lifepoint Health. Angela is an active member of several professional organizations, including the Tennessee Health Information Management Association (THIMA), where she is currently serving as Past President, the American Health Information Management Association (AHIMA), the Association of Clinical Documentation Improvement Specialists (ACDIS), and the Healthcare Financial Management Association (HFMA). She is recognized as a subject matter expert and has delivered presentations at local, national, and international conferences. Angela holds a Bachelor of Science degree in Health Administration from Stephens College, as well as a Master of Business Administration and a Doctor of Business Administration with a focus in Healthcare Administration from Trevecca Nazarene University in Nashville, TN.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Enhancing Outcomes with CDI-Coding-Quality Collaboration in Acute Care Hospitals

Enhancing Outcomes with CDI-Coding-Quality Collaboration in Acute Care Hospitals

Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.

November 21, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Outpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

September 5, 2024
Advanced Outpatient Clinical Documentation Integrity: Mastering Complex Narratives and Compliance

Advanced Outpatient Clinical Documentation Integrity: Mastering Complex Narratives and Compliance

Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.

September 12, 2024

Trending News

Featured Webcasts

Patient Notifications and Rights: What You Need to Know

Patient Notifications and Rights: What You Need to Know

Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.

December 5, 2024
Navigating the No Surprises Act & Price Transparency: Essential Insights for Compliance

Navigating the No Surprises Act & Price Transparency: Essential Insights for Compliance

Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks.  Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.

November 19, 2024
Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.

October 24, 2024
The OIG Update: Targets and Tools to Stay in Compliance

The OIG Update: Targets and Tools to Stay in Compliance

During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.

September 19, 2024

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24