CMS Unveils 2024 Medicare PFS, OPPS Proposed Rules

The OPPS proposal did not feature reference to several high-profile issues industry leaders have been awaiting reform on.

Federal officials yesterday unveiled a pair of proposed rules, featuring potential adjustments to the Medicare Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for the 2024 calendar year.

The Centers for Medicare & Medicaid Services (CMS) announcement highlighted rate updates, the promotion of health equity, and the expansion of access to critical medical services such as behavioral healthcare and certain oral health services, while also serving to advance the Biden-Harris Administration’s “Cancer Moonshot” mission to accelerate the fight against cancer – all in the PFS proposed rule alone.

“At CMS, our mission is to expand access to healthcare and ensure that health coverage is meaningful to the people we serve,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “CMS’s proposals in the proposed physician payment rule would help people with Medicare navigate cancer treatment and have access to more types of behavioral health providers, strengthen primary care, and for the first time, allow Medicare payment for services performed by community health workers.”

“CMS continues to demonstrate commitment to advancing health equity and building a stronger Medicare program,” added Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare. “If finalized, the proposals in this rule ensure the people we serve experience coordinated care focused on treating the whole person, considering each person’s unique story and individualized needs – physical health, behavioral health, oral health, social determinants of health – and are inclusive of caregivers, which are all so important to providing the care that people with Medicare deserve.”

Officials said that overall, proposed payment amounts under the PFS would be reduced by 1.25 percent compared to 2023, in accordance “with factors specified by law.” CMS proposed increases in payments for many visit services, such as primary care, necessitating offsetting and budget-neutrality adjustments to all other services paid under the PFS. The proposed 2024 PFS conversion factor is $32.75, a decrease of $1.14, or 3.34 percent, from 2023.

The proposed rule also features adjustments to coding and payment for several new services to help underserved populations, including what officials described as “addressing unmet health-related social needs that can potentially interfere with the diagnosis and treatment of medical problems.” This included a proposal to pay for certain caregiver training services in specified circumstances, and the introduction of separate coding and payment for community health integration services.

The Cancer Moonshot provision seeks to ensure that everyone diagnosed with cancer gains access to services meant to help patients navigate treatment for it and other serious illnesses, to include care involving peer support specialists. These changes also included the proposed provision of coding and payment availability for social determinants of health (SDoH) risk assessments, which could be furnished as an add-on to an annual wellness visit or in conjunction with an evaluation and management (E&M) visit.

The press release on the proposed rule issued by CMS also cited newly proposed access to oral and dental health services for beneficiaries, support of patients’ “emotional and mental well-being through their behavioral healthcare,” and the U.S. Department of Health and Human Services (HHS) Initiative to Strengthen Primary Care.

“CMS is also continuing to promote whole-person care in the Medicare Shared Savings Program, the largest Accountable Care Organization (ACO) program in the country,” the release read. “CMS is proposing changes to the assignment methodology that would better promote access to accountable care for individuals who see nurse practitioners, physician assistants, and clinical nurse specialists for their primary care services. CMS is also proposing changes to the financial benchmarking methodology to better encourage participation by ACOs serving complex populations. In total, these proposals are expected to increase participation in the Shared Savings Program by roughly 10 to 20 percent, which will provide additional opportunities for beneficiaries to receive coordinated care from ACOs.”

In a related announcement, CMS noted that it is seeking to bolster the Medicare Diabetes Prevention Program (MDPP) Expanded Model to further increase participation and access in underserved communities. Its proposal would extend Public Health Emergency (PHE) flexibilities for four years, which officials said would allow all MDPP suppliers to continue to offer MDPP services virtually using distance learning delivery through 2027, as long as they maintain an in-person Centers for Disease Control and Prevention (CDC) organization code.

As for the OPPS proposed rule, a 60-day comment period will end in mid-September and be followed by a final rule expected in November. In addition to proposing payment rates, the rule included proposed policies that overlap somewhat with the PFS plan: “promoting health equity, expanding access to behavioral healthcare, improving transparency in the health system, promoting safe, effective, and patient-centered care, and addressing medical product shortages.”

Officials said the OPPS policies will affect approximately 3,500 hospitals and approximately 6,000 Ambulatory Surgical Centers (ASCs), with hospital price transparency proposed policies impacting over 7,000 institutions licensed as hospitals.

The new OPPS payment rates for hospitals that meet applicable quality reporting requirements result in a net 2.8-percent increase.

“In the CY 2019 OPPS/ASC final rule with comment period, we finalized a policy to apply the productivity-adjusted hospital market basket update to ASC payment system rates for an interim period of five years (CY 2019 through CY 2023), during which time we would assess whether there is a migration of the performance of procedures from the hospital setting to the ASC setting as a result of the use of a productivity‑adjusted hospital market basket update,” CMS said in a fact sheet. “However, the impact of the COVID-19 PHE on healthcare utilization, in particular in CY 2020, was tremendously profound, particularly for elective surgeries, because many beneficiaries avoided health care settings, when possible, to avoid possible infection from the SARS-CoV-2 virus. Therefore, for this CY 2024 OPPS/ASC proposed rule, we are proposing to extend the five-year interim period an additional two years – through CY 2024 and CY 2025. This will enable us to gather additional claims data further removed from the COVID-19 PHE to more accurately analyze whether the application of the hospital market basket update to the ASC payment system had an effect on the migration of services from the hospital setting to the ASC setting.”

The OPPS proposed rule also features a proposal to establish an Intensive Outpatient Program (IOP) under Medicare – complete with a scope of benefits, physician certification requirements, coding and billing, and payment rates under the IOP benefit. IOP services would be furnished in hospital outpatient departments, Community Mental Health Centers (CMHCs), Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs), if finalized, to “address one of the main gaps in behavioral health coverage in Medicare.”

In a related move, CMS is also proposing to establish two IOP Ambulatory Payment Classifications (APCs) for each provider type: one for days with three services per day, and one for days with four or more services per day.

Dr. Ronald Hirsch, Vice President of the Regulations and Education Group for R1 RCM Inc. and a permanent fixture on the Monitor Mondays weekly Internet radio broadcast (and longtime contributor to RACmonitor), said the OPPS announcement was noticeably silent on several issues some in the industry hoped would be addressed.

“For listeners to Monitor Mondays and RACmonitor eNews readers, the … proposed rule makes no significant changes, without any modifications to the Two-Midnight Rule, no mention of the case-by-case exception, no deletions from the Inpatient-Only List (IOL), and only a few codes proposed to be added to the IOL for newly assigned codes such as HCPCS 0646T trans-catheter tricuspid valve implantation,” Hirsch said. “On the other hand, it appears CMS is not happy with the efforts that hospitals have made to comply with the price transparency rules, and they have proposed significant changes to the requirements and the enforcement methods.”

To view a fact sheet on the 2024 Physician Fee Schedule proposed rule online, please visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule

To view a fact sheet on the 2024 OPPS proposed rule, go to: https://www.cms.gov/newsroom/fact-sheets/cy-2024-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

Mark Spivey is a national correspondent for RACmonitor and ICD10monitor who has been writing and editing material about the federal oversight of American healthcare for nearly 15 years. He can be reached at mcspivey33@gmail.com.