Hospitals and other providers should be closely monitoring recent legislation moving through the House of Representatives. The Promoting Access to Treatments and Increasing Extremely Needed Transparency (PATIENT) Act (H.R. 3561) is being advanced in the House of Representatives by unanimous bi-partisan support. In addition to modifying price transparency reporting, the bill includes new reporting requirements, regulatory filings, and payment reductions. Key highlights include:
- Reimbursement Cut for Grandfathered Off-Campus Drug Administration Services: Beginning in 2025, Drug administration services at grandfathered off-campus hospital outpatient department (“HOPD”) locations will no longer receive full OPPS reimbursement. A site neutral rate equal to the current site-neutral rate of 40% of the OPPS rate will be phased in over 4 years. The services subject to the reduction will be grouped under a new ambulatory payment classification (APC) group.
- Advis Insight: The APC grouping is not set, so details on losses can only be estimated. The AHA has estimated losses of 54.2M to hospitals in year 1, growing to 3 billion over 10 years. In addition to this proposal, the American Hospital Association has shared a fact sheet here, with two additional site neutral impact proposals circulating in the House. The first would reimburse all services within off-campus HOPDs at 40% of the OPPS, expanding beyond the current site neutral reimbursement for G0463 clinic visits and the proposed drug administration services noted above. The second proposal goes even further to realign payment depending on which venue type most commonly renders categories of service, and notably would include on-campus HOPDs. These proposals each highlight the continually increasing scrutiny on HOPD compliance and reimbursement.
- Off-Campus Outpatient Department NPI & Attestation Requirements: By January 1, 2026, all off-campus outpatient departments must obtain (1) a unique NPI to receive payment, and (2) submit during the preceding 2-year period ending on January 1, 2026 (or 2-year period ending on the date services are offered) a Provider-Based Attestation to document compliance with the regulations at 42 C.F.R. 413.65.
- Advis Insight: Although compliance with the Provider-Based requirements is not new, a mandatory attestation process is a major departure from the voluntary process in place today. Many, if not most, providers do not have attestations approved by CMS for their provider-based locations, and locations can number in the dozens for a single hospital. Advis has decades of experience in leading organizations through the CMS provider-based attestation process. Contact us today to assess your organization’s compliance and prepare for increased scrutiny.
- Mandatory Health-Related Ownership Reporting: By January 1, 2025 and annually thereafter, hospitals, physician groups (25+ physicians or owned by hospital/health plan/private equity/venture capital), ASCs, and Freestanding Emergency Departments (FEDs) must report information to HHS regarding mergers, acquisitions, changes in ownership, and the reporting entity business structure for the prior 1-year period. Hospitals must include additional details regarding debt ratios, average amount of debt, real estate, and capital gains investments/taxes if it is a non-profit. Failure to report can lead to fines of up to $5,000,000.
- Advis Insight: With leeway to further define required reporting information, provider organizations should closely monitor the status of this bill and implementing regulations should it be passed. Reporting requirement must be socialized and built into existing organizational processes to ensure accurate and timely reporting.
The PATIENT Act also includes other provisions aimed at strengthening price transparency accuracy and compliance, increasing oversight of PBM practices, banning spread pricing by PBMs, and delay for two years ~$8 billion in annual Medicaid Disproportionate Share Hospital payment reductions scheduled to begin in October.
Advis will continue to follow this important update and offer additional guidance as it becomes available. For any questions regarding this update, or for organizational assistance with any other healthcare regulatory or operational matter, please contact an Advis expert or call 708.478.7030.