Provider Roundtable gives CMS feedback, gets results
CMS asked for provider feedback on the proposed 2004 OPPS rule and got just that from the OPPS Provider Roundtable (PRT), a group of 18 providers from across the country who presented operational coding and billing feedback in more than 30 pages of comments. Read the comments and addenda.
“Providers are on the front lines, dealing with OPPS on a daily basis,” says Jugna Shah, MPH, of Nimitt Consulting (St. Paul, MN). “They know what issues they struggle with and have a lot to say about surviving under OPPS. Yet, they haven’t always mobilized to give CMS feedback on their daily operational challenges under the system.” Shah served as the PRT’s facilitator and Nimitt Consulting, HCPro Inc., and 3M Health Information Systems sponsor the group.
CMS’ final Rule reflects many of the comments the PRT submitted and highlights that the group was on track with its views, Shah says. The PRT’ comments appear throughout several sections of the final Rule. “It was very rewarding to see the results of our effort to communicate the ‘real world’ impact of the OPPS rules. Several of the changes CMS originally proposed for 2004 were not finalized as a direct result of our comments. This is a winning situation for both providers and beneficiaries,” says PRT member Jennifer Artigue, RHIT, CCS, Assistant Director of Revenue Management Our Lady of Lourdes Regional (Lafayette, LA).
The PRT covered the basics in its comments, but also discussed unique issues, including:
- Providers make service delivery decisions based on the financial impact of APC/OPPS on their organizations. The question of expanding, eliminating, or consolidating service lines is often dependent on how persuasive clinic managers can be with their finance departments despite losses that may result from fluctuating APC payment rates. The PRT offered a number of concrete examples of facilities that curtailed or eliminated services due to year-to-year payment rate changes under OPPS.
- The PRT told CMS that the
introduction of a generic drug does not automatically translate into
its adoption by providers. Migrating to generic equivalents is affected
by a number of factors that include: when the brand name product goes
off-patent, when generic equivalents become available, when hospitals
determine the generics are safe, when existing contracts can be renegotiated,
and whether enough of the generic equivalents is available when they
appear on the market. CMS listened to the PRT and will use the same
data and method for creating payments for these drugs as it does for
other separately payable drugs (e.g. charges reduced to costs).
- The PRT members developed
a chart based on their facilities’ data to demonstrate that blood
services and product costs are inappropriately low. The group compared
their 2003 data to both CMS’ 2003 actual and 2004 estimated reimbursement
to show the payment impact of the proposed 2004 decreased payment rates.
The PRT also raised questions about the need to have separate CPT codes
for autogolous blood and directed donor blood. CMS responded to this
issue and agreed to keep blood payments frozen at the current 2003 payment
levels. In addition, CMS agreed to review the PRT’s questions on
the autologous and directed donor blood.
- CMS’ inpatient-only list creates problems as a result of how providers, payers, and others in the health care community interpret and use the list. A patient may require a procedure from the inpatient-only list in order to be stabilized, but providers have no mechanism that will allow payment in the outpatient setting other than admitting the patient to the inpatient setting for purely administrative reasons. The PRT asked CMS to consider paying for these procedures either directly or through the use of a modifier. CMS did not agree to do anything at the present time, but the issue has, at least, been placed on its radar for future consideration.
The PRT also pointed out problems in how the McKesson InterQual SIMplus interprets CMS’ inpatient-only list. SIMplus setting notes for many procedures indicate that Medicare designates the procedures as “outpatient”, based, apparently, on the fact that the procedures are not listed on the inpatient-only list. This conflicts with CMS’ definitions, contained in various sections of the Hospital Manual, of inpatient, outpatient, and observation care. The PRT asked CMS to clarify this issue, reasoning that the fact that a service is not on the inpatient-only list does not mean that it has to be provided in the outpatient setting. CMS responded to this issue, agreed with the PRT, and provided clarifications in the final Rule.
The PRT also commented on:
- Setting national facility E/M guidelines;
- Proposals for drug administration payment;
- Changes to payment status indicators;
- Cessation of creating unnecessary HCPCS codes when appropriate CPT codes already exist;
- Reducing inconsistencies across FIs by releasing national guidance on special topics such as infusion and injection charging, and modifiers.
According to Shah, the final Rule reflects many of the PRT’s comments and shows that the time the 18 individuals spent in helping the government think about possible changes to OPPS was well worth it. The group made focused, data-driven comments and specific recommendations rather than stating obvious complaints about payment rate decreases. Shah believes this positive and constructive approach was more appealing to CMS that the “sky is falling” approach too often found in industry comments.
What’s next?
The PRT will continue to review CMS Program Memos, and is already working on addressing concerns related to NCCI edits. Early in 2004, the group plans to testify before the APC Advisory Panel on several topics, including observation services. The group members will collaborate again on the 2005 OPPS proposed rule.
