The Centers for Medicare and Medicaid Services (CMS) by Nov. 1 will begin to reprocess claims for some outpatient clinic visit services provided at excepted off-campus provider-based departments at the same rate as at nonexcepted off-campus provider-based departments under the Physician Fee Schedule.

The reprocessed claims will affect certain claims with dates of service between Jan. 1 – Dec. 31, 2019. Providers do not need to do anything to have claims reprocessed but must refund the coinsurance difference to patients or payers who paid higher coinsurance rates based on new remittance advice information.

The 2019 Calendar Year 2019 Outpatient Prospective Payment System (OPPS) Rule finalized payment for certain outpatient clinic visit services provided at excepted off-campus provider-based departments at the same rate as nonexcepted off-campus provider-based departments. Previously, CMS and Medicare beneficiaries paid more for the same type of clinic visit in a hospital outpatient department vs. in a physician office setting.

Under the 2019 OPPS final rule, CMS reduced payments in off-campus provider-based departments to 70% of the full rate in 2019 and to 40% in 2020. In September 2019, the U.S. District Court for the District of Columbia declared the rule providing reduced payments at outpatient provider-based departments invalid. CMS then reprocessed 2019 claims that had been paid at the reduced 70% rate to restore the 100% payment rate. Then, in July 2020, U.S. Court of Appeals for the D.C. Circuit reversed the district court ruling, upholding the original CMS final rule. The agency is now reprocessing claims based on the ruling upholding the site-neutral payment policy for off-campus outpatient hospital clinic visits. Read more in MLN Connects.

Keywords: ACC Advocacy, Ambulatory Care, Outpatient Clinics, Hospital, Prospective Payment System, Fee Schedules, Deductibles and Coinsurance, Physicians' Offices, Medicare, Centers for Medicare and Medicaid Services, U.S.

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