Payment Update: CMS to again reprocess 2019 outpatient clinic visit claims at excepted off-campus hospital outpatient departments – this time at 70% of Outpatient Prospective Payment System rate vs. 100%

In a recent mlnconnects notice, the Centers for Medicare & Medicaid Services (“CMS”) announced that, by November 1, 2021, it will begin reprocessing 2019 claims for outpatient clinic visit services (G0463) provided at excepted off-campus hospital outpatient departments (“HOPDs”), i.e., those HOPDs that were established prior to November 2, 2015.  Instead of the full Outpatient Prospective Payment System (“OPPS”) payment, clinic visit claims with dates of service between January 1, 2019 and December 31, 2019 will be reprocessed at 70% of the OPPS in accordance with the site-neutral rule outlined below.  CMS notes that it will reprocess all affected claims; hospitals must refund the coinsurance difference to patients (or payers) who paid the higher coinsurance rates based on the new remittance advice information.

This site-neutral rule was implemented as part of CMS’ 2019 OPPS Final Rule.  In part, the 2019 OPPS Final Rule extended site-neutral reimbursement to clinic visits (G0463) performed at excepted off-campus HOPDs.  Effective January 1, 2019, clinic visits at these locations were paid 70% of the OPPS rate, with a further reduction to 40% of the OPPS rate for 2020 and beyond.

This policy has been the subject of ongoing litigation, as follows:

  • September 17, 2019: U.S. District Court for the District of Columbia declared invalid the CY 2019 payment rule that provided for the reduction for clinic visits provided at excepted off-campus HOPDs.
  • January 1 – July 2020: CMS reprocessed CY 2019 claims paid at the reduced payment rate of 70% to restore the 100% payment in accordance with the district court decision.
  • July 17, 2020: The U.S. Court of Appeals for the D.C. Circuit reversed the district court ruling, upholding CMS’ site-neutrality payment policy for clinic visits provided at excepted off-campus HOPDs.
  • June 28, 2021: The U.S. Supreme Court declined to hear the American Hospital Association’s appeal.

For any questions regarding this payment update, or for any other healthcare or operational matters, please contact Advis or call (708) 478-7030.

Published: October 12, 2021