• Angel Callaway, CPC, CPB

Outpatient Clinic Visit Service Payment Update

CMS will begin reprocessing claims submitted with POS 22 Outpatient Clinic visit services that were provided at a excepted off-campus Provider Based Deptartment (PBD's) to pay at the same rate as non-excepted off-campus PBDs. The dates of service affected are between Jan1-Dec. 31,2019.


Why is CMS reprocessing the claims? Nov.21, 2018 the 2019 OPPS Rule paid the excepted off-campus PBDs at the same rate as the non-excepted off-campus PBDs for the services that fell under the Physician Fee Schedule (PFS). Prior to this CMS and Medicare patients often paid more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.


Medicare reduced payment to 70% of the full OPPS rate in off-campus PBS in 2019. In 2020 this was changed to 40%. The U.S. District Court of District Columbia declared the 2019 rule invalid for visits provided at excepted off-camputs PBDs. From Jan1-July 2020 CMS reprocessed CY2019 claims paid at the70% reduced rate to restore the 100% payment rate in accordance with the court ruling. July 17, 2020 The US Court of Appeals for the D.C. Circuit reversed the district court ruling, upholding CMS volume control site-neutrality payment policy for off-campus outpatient clinic visits.


What does this mean? CMs will reprocess claims that paid at 100% to pay at 70% of the OPPS rates. You do not need to do anything. CMS will reprocess all affected claims. However, you must refund the coinsurance difference to patients (or payers) who paid the higher coinsurance rates based on the new remittance advice.


This is not the end of the discussion on this matter. American Hospital Association will ask the U.S. Supreme Court to review the appeals court decision. Once the Supreme Court makes its ruling we could see further reprocessing of claims.

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