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CMS to Consider Provider-Based Concerns with Budget Act Implementation

Posted on April 6, 2016 in Health Law News

Published by: Hall Render

CMS posted a notice on its website inviting stakeholders to submit questions and/or scenarios to CMS regarding implementation of the Budget Act provision impacting OPPS coverage for off-campus provider-based departments. The full notice, which can be found here, follows.

Note Regarding Implementation of Section 603 of the Bipartisan Budget Act of 2015

CMS will be presenting our proposals for implementing Section 603 of the Bipartisan Budget Act of 2015 through the CY 2017 Outpatient Prospective Payment System Proposed Rule. While we cannot provide guidance on Sec. 603 prior to the proposed rule, if there is a scenario regarding implementation of Sec. 603 that you are concerned about and want to call attention to it for the proposed rule, we have created a mailbox for the public to send these scenarios, which is

While we cannot guarantee that information or questions sent to this mailbox will be addressed in the proposed rule, this is the best way to alert us to a scenario. The public will have the opportunity to comment on the proposed rule per the standard notice and comment rulemaking process.

The CY 2017 OPPS proposed rule is expected in July. Hall Render encourages providers to make use of this opportunity to raise issues and concerns with CMS prior to rulemaking. For example, the Budget Act effectively treats a remote location of a hospital (i.e., a second inpatient facility) as an on-campus location of the hospital. This is consistent with the new reporting requirements for off-campus locations (CMS 1500 place of service code 19 and the UB PO modifier) that took effect January 1, 2016, which treat remote locations as on-campus locations of the hospital. This is different, however, than the current provider-based regulation, which treats a remote location of a hospital as an off-campus site, triggering the joint venture restriction and management contract rule, as well as co-insurance notice requirements. The rulemaking should align the regulation with this new treatment of remote locations and address other issues raised by the Budget Act, including:

  1. How non-grandfathered sites will bill for services;
  2. Billing and payment for services only covered under the OPPS;
  3. Treatment of facilities under development;
  4. Treatment of grandfathered facilities that are the subject of a provider-based denial;
  5. Whether grandfathered sites can move or add new services; and
  6. Impact on the 340B Program and whether new off-campus locations may be considered “Child Sites.”

If you have questions regarding the Budget Act, provider-based requirements or need assistance with appropriate CMS communications, please contact:

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