2016 Medicare Payment Rules Finalized

By Maureen Leddy, JD, Manager, Policy and Strategic Alliances, ACCC

The Centers for Medicare & Medicaid Services (CMS) on Oct. 30, 2015, released the final 2016 Physician Fee Schedule and Outpatient Prospective Payment System rules. With the exception of radiation therapy codes, the final rules align quite a bit with the proposed rules. A preliminary summary is included below. Stay tuned for detailed summaries and analysis on an upcoming ACCC members-only conference call on these 2016 final rules.

Highlights of 2016 PFS Final Rule

Radiation Oncology

In a noteworthy departure from the proposed 2016 PFS rule, CMS did not finalize new radiation therapy treatment payment codes. CMS responded to concerns expressed by ACCC and other stakeholder groups and delayed implementation of new radiation oncology codes, continuing use of current G-codes and values for 2016. However, the agency did finalize its proposal to increase the linear accelerator equipment utilization rate assumption from 50 percent to 70 percent over two years. CMS continues to seek empirical data on costs and usage of capital equipment, including linear accelerators.

Advance Care Planning

For 2016, CMS finalizes its proposal to establish separate payment for advance care planning services, consistent with the recommendations of the American Medical Association and other stakeholders, including ACCC. These new codes compensate providers for shared decision-making conversations at various stages of a patient’s illness.

Biosimilars

For 2016, CMS finalized its proposal to include all biosimilars of a reference biological product within the same billing and payment code. ACCC had commented against this proposal, raising concerns regarding traceability and administrative burdens expected with the use of a single code. While ACCC supports efforts to increase patient access to biologics, ACCC maintains that a system must be in place to track the specific biosimilar product used for each patient.

“Incident To”

CMS finalized its proposal to clarify requirements for billing for “incident to” services. CMS now formally requires that the physician or practitioner billing for “incident to” services must have directly supervised the auxiliary personnel providing these services. Addressing stakeholder concerns about the treating physician’s supervisory role in “incident to” services, the final rule clarifies that the supervising physician need not be the treating physician for billing purposes.

Highlights of 2016 OPPS Final Rule

CMS finalized its proposed cut in hospital outpatient payment rates of – 0.3 percent. Within this calculated –0.3 percent rate update is a –2 percent cut, applied due to the agency’s calculation of excess packaged payment for laboratory services in 2014. As a result of this year’s rate cut due to miscalculations in packaging policies, ACCC urged CMS to proceed cautiously with any additional packaging proposals to ensure future negative adjustments would not be necessary. However, CMS finalized its proposal to expand conditionally packaged services to include three new APCs: level 4 minor procedures, and level 3 and 4 pathology services. CMS notes that packaging of these services is consistent with the agency’s overall packaging policy.

Advance Care Planning

ACCC had also advocated for separate payment under advance care planning codes in the hospital outpatient setting. The 2016 OPPS final rule calls for conditionally packaging payment for these services, permitting separate payment in the hospital outpatient setting in limited circumstances.

Biosimilars

In the 2016 OPPS final rule, CMS finalized its proposals to pay biosimilars based on ASP+ 6% of the reference biologic product, and to allow biosimilars to be eligible for pass-through status. ACCC supported these proposals, noting that providing equivalent payment rates in the physician office and outpatient setting for biosimilars removes incentives to select one setting over another.

Two-Midnight Rule

CMS also finalized proposed changes to its two-midnight rule regarding hospitalization payment status. CMS will now allow certain patients not expected to meet the two-midnight stay requirement for inpatient status to still be classified as inpatient. CMS indicates that qualifying patients are those that require inpatient hospital care, as determined by the admitting physician and supported by the medical record, despite the expectation that their stay will last less than two midnights.

ACCC continues to analyze the 2016 payment rules and will update its members in the coming weeks.

 

SGR Repeal: Are We There Yet?

By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

As ACCC members know, last week brought unprecedented momentum on an issue physicians and Congress have been struggling with for over a decade: repealing the sustainable growth rate (SGR). Just days before the current SGR “patch” expired, the House of Representatives overwhelmingly passed H.R. 2, the Medicare Access and CHIP Reauthorization Act, legislation that would permanently replace the SGR formula with stable Medicare payment updates and encourage physicians to increasingly participate in alternative payment models. The bill builds on last year’s bipartisan, bicameral compromise that ultimately hit roadblocks when legislators struggled to find a way to pay for it.

The Senate was expected to take up the House bill, but on March 27, the chamber recessed for two weeks, leaving a very small window to consider the bill when they return on April 13.

Senate Majority Leader Mitch McConnell has said the bill should move “very quickly” when the chamber comes back into session, and there is “every reason” to believe the bill will pass.

Meanwhile, the current “patch” expired March 31, and CMS has indicated that it will hold claims for two weeks, or 10 business days, through April 14.

We’re in the homestretch; we’re closer to a permanent fix to the SGR than we have ever been before. But are we there yet? Not quite. Now is the time to contact your Senators, and urge them to support passage of H.R. 2, to ensure that physicians have the predictable, appropriate payments they need to continue to provide high-quality cancer care.

Stay tuned. And make your voice heard. Contact your Senators today.