Summary of Major Provisions

These highlights are by no means a comprehensive listing of all provisions within the OPPS Proposed Rule, but provide a listing of significant items applicable to multiple facilities.

General

A. Increasing Price Transparency of Hospital Standard Charges: On the heels of the Executive Order on Improving Price and Quality Transparency in American Health to Put Patients First, CMS has proposed a regulation to implement this order.  In CMS’ opinion, this proposed rule enhances the prior agency guidance requiring hospitals to publicize the standard changes in a machine-readable format effective January 1, 2019.  This rule proposes to 1) clarify the definitions of “hospital”, “standard charges”, and “items and services”; 2) require the machine-readable format for standard charges on all hospital items and services; 3) require making public payer-specific negotiated charges for a limited number of “shoppable” services displayed in a “consumer-friendly” manner and: 4) implement a monitoring mechanism for hospital noncompliance and penalties for noncompliance, including warnings, corrective action plans and civil monetary penalties. 

1. Hospital – An institution in any State in which State or applicable local law provides for the licensing of hospitals and which is licensed as a hospital pursuant to such law, or is approved by the agency of such State or locality responsible for licensing hospitals as meeting the standards established for such licensing

Standard Charge – Hospital’s gross charge and payer-specific negotiated charge for an item or service

Items and Services – All items and services (including individual items and services and service packages) provided by a hospital to a patient in connection with an inpatient admission or an outpatient department visit for which the hospital has established a charge

2. The proposal referencing all standard changes would require that hospitals make public their standard changes (both gross charges and payer-specific negotiated charges) for all items and services online in a machine-readable format.

3. Consumer-friendly – What exactly is “shoppable” and “consumer-friendly”? How does CMS attempt to qualify and quantify these criteria?

Shoppable is defined as a service that can be scheduled by a consumer in advance.

CMS goes on to propose the following requirements of hospitals:

– Display payer-specific negotiated charges for at least 300 shoppable services, including 70 CMS-selected services and 230 hospital -selected services. If the hospital does not provide the 70 CMS services, the hospital-selected services must compensate, such that the total of the listing is 300 services.

– Ensure this information is displayed prominently on a publicly-available webpage

– Updated annually

4. Monitoring and Enforcement

– Monitor

– Warnings

– CAP (Corrective Action Plan)

– Monetary penalty – Up to $300/day; publicized on CMS website; Appealable to the ALJ

B. Supervision of Hospital Outpatient Therapeutic Services: CMS is proposing to change the minimum required level of oversight from direct to general supervision for ALL hospital outpatient therapeutic services, ensuring a standard minimum level of guidance. This change is based on studies conducted with respect to the level of service provided between acute-care hospitals and critical access hospitals, which have recently had different levels of enforcement requirements, based on the moratorium on enforcement of this requirement for CAHs.

Prospective Payment System (PPS) Specific

• Payment Differentials: CMS is proposing to increase the policies to reduce the payment differentials between certain outpatient sites, with the goal of improving the quality of patient care while lowering costs.
• Changes to the Inpatient Only List: There are proposed changes to the procedures covered by this listing.  For example, CMS is proposing to remove total hip arthroplasty from the inpatient-only list.  However, please review for the proposed Federal Register for a comprehensive listing.
• Wage Index: CMS is proposing to use the FY 2020 IPPS wage index as the wage index for OPPS.  This includes the IPPS adjustment to address the wage index variations between high and low wage index value hospitals – increasing the wage index for certain low wage index hospitals.