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CMS to Reprocess 2019 OPPS Claims at Site Neutral Rates

The Centers for Medicare & Medicaid Services (CMS) will begin reprocessing outpatient claims to excepted off-campus provider-based departments (PBDs) at the lower site neutral payment rate it established in the calendar year 2019 Outpatient Prospective Payment System (OPPS) final rule.

The 2019 site neutral payment rate for excepted PBDs applies to outpatient office visits (health care common procedure coding system code G0463) and is 70 percent of the OPPS rate for the same service. The decision to pay hospitals at the lower payment rate is a result of a July 2020 decision of the Court of Appeals for the D.C. Circuit upholding CMS’ 2019 policy, which was under legal challenge.

In 2019, CMS began paying excepted off-campus PBDs at a phased-in site-neutral payment rate of 70 percent, even though these PBDs were specifically excepted by the Bipartisan Budget Act of 2015. CMS then fully phased in the 40 percent of OPPS payment rate to excepted off-campus PBDs in 2020. This policy has been subject to litigation. In a 2019 case, a district court ordered CMS to repay hospitals at the full OPPS payment rate. Accordingly, in 2020, CMS reprocessed 2019 claims that had been paid at the reduced site neutral rate to be paid at the full OPPS payment rate. Due to the July Court of Appeals decision, CMS will start reprocessing 2019 claims again, this time at the 70 percent of OPPS payment rate by July 1.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Shahid Zaman is a senior policy analyst at America's Essential Hospitals.

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