August 11, 2021

Last week, we provided highlights from the Medicare Hospital Outpatient Prospective Payment System (OPPS) Proposed Rule (PR) for 2022. Due to the enormity of the PR, we were forced to provide our summary in multiple parts. This article will provide additional details on what the government has planned for outpatient departments in the coming year.

Partial Hospitalization Program

According to a PR fact sheet issued by the Centers for Medicare and Medicaid Services (CMS), the 2022 PR would update Medicare payment rates for Partial Hospitalization Program (PHP) services furnished in hospital outpatient departments and Community Mental Health Centers (CMHCs). The PHP is a structured intensive outpatient program consisting of a group of mental health services paid on a per diem basis under the OPPS, based on PHP per diem costs.

CMS is proposing to maintain the existing unified rate structure, with a single PHP Ambulatory Payment Classification (APC) for each provider type for days with three or more services per day. In order to maintain consistency with OPPS for 2022 rate-setting, CMS is proposing to use 2019 claims and the cost information from prior to the COVID-19 PHE.

Radiation Oncology Model

The 2022 PR includes the following proposals to modify the Radiation Oncology (RO) Model’s timing and design:

Begin the RO Model on January 1, 2022, with a 5-year Model performance period (ending December 31, 2026).
Change the baseline period from 2016-2018 to 2017-2019.
Lower the discounts to 3.5 percent (Professional Component) and 4.5 percent (Technical Component).
Remove brachytherapy from the list of included modalities under the RO Model so that it would still be paid FFS.
Revise the cancer inclusion criteria under the RO Model.
Where a beneficiary switches from traditional Medicare to Medicare Advantage during an episode before treatment is complete, CMS would consider this an incomplete episode and RT services would be paid the traditional Medicare rate instead of being paid under the RO Model.
Adopt a policy that would provide flexibility to reduce administrative burden of Model participation, including reporting requirements, and/or adjust the payment methodology as necessary when extreme and uncontrollable circumstances exist.
Exclude hospital outpatient departments participating in the Community Transformation track of the CHART Model from participation in the RO Model. For the CHART ACO Transformation track, CMS would follow the same policy for overlap between the RO Model and the Medicare Shared Savings Program ACOs.
Only hospital outpatient departments that are participating in the Pennsylvania Rural Health Model (PARHM) would be excluded from the RO Model, rather than those that are eligible to participate in PARHM.
Remove liver cancer from the RO Model.
For more information on the RO Model, visit: https://innovation.cms.gov/initiatives/radiation-oncology-model/.

Outpatient Quality Reporting Program

The Hospital Outpatient Quality Reporting (OQR) Program is a pay-for-reporting quality program for the hospital outpatient department setting. The Hospital OQR Program requires hospitals to meet quality reporting requirements, or receive a reduction of 2.0 percentage points in their annual payment. In the 2022 OPPS/ASC proposed rule, CMS:

Adopts three new measures, including the COVID-19 Vaccination of Health Care Personnel (NQF #0431);
Makes the reporting of two voluntary or suspended measures mandatory;
Removes two measures; and
Updates the validation policies of the Hospital OQR Program to reduce provider burden and improve processes.
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The PR will have a 60-day comment period, ending on September 17, 2021. The Final Rule is scheduled to be released in early November. To view the OPPS Proposed Rule for 2022, go to the following link: 2021-15496.pdf (federalregister.gov). If you have questions about how we at MiraMed Global Services can help with your business needs, please contact us at info@miramedgs.com.