While CMS (the Centers for Medicare & Medicaid Services) usually releases new rules in the afternoon, on July 10 they chose to release the 2025 Outpatient Prospective Payment System (OPPS) Proposed Rule before 9 a.m. At 984 pages, the rule contains the usual adjustments to payment rates for both hospital outpatient services and ambulatory surgery center care, along with more efforts to promote health care equity and improve maternal health.
From the utilization management side though, it is generally status quo. The rule makes no adjustments to the Two-Midnight Rule, adds only three seldom-used codes related to complex liver procedures to the inpatient-only list, removes no surgeries from the inpatient-only list, and add several surgeries to the ambulatory surgery center covered procedure list, most notably placement and removal of a leadless pacemaker.
As has been discussed on Monitor Mondays and Talk Ten Tuesdays, the Supreme Court overturn of Chevron Deference creates an environment where many of the policies followed by hospitals are potentially subject to challenge in the courts. Perhaps CMS felt it best to avoid any major changes for 2025 to maintain some degree of regulatory stability, at least for now.
Humana recently settled a whistleblower lawsuit and agreed to pay $90 million. One of its former actuaries had accused the health insurer of overcharging the
If you have been listening to the discussions on Monitor Monday and Talk Ten Tuesday about the use of the new HCPCS code G2211, you
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