NEWS YOU CAN USE: Find Out Why Your Guidelines Are Out of Sync

• Get on CMS’ wavelength with the 2006 OPPS final rule

This year’s final rule for the outpatient prospective payment system (OPPS) brings many fresh changes--different drug payments, a hefty rate increase for acute care facilities, and outlier thresholds. Read this to make sure your facility’s on target with the demands of 2006.
Trust 2 rules for outlier payments:

The government has budgeted only 1 percent of all OPPS payments to cover your facility’s costs for outlier patients. But these patients are by definition costly, so it’s crucial that you document your expenses to receive outlier reimbursement. When you add up the total, remember that to qualify as an outlier, the cost of your services needs to meet these two guidelines, according to CMS:
1. The cost must exceed 1.75 times the regular ambulatory payment classification (APC) payment rate, and

2. The cost also needs to be more than the sum of the APC rate plus $1,250.

Note: For the second criterion, the proposed rule asked for the sum of the APC rate and $1,575 …quot; which didn’t fly in the end.
Calculate your average:

In 2006, hospitals will receive an average 2.2 percent increase in Medicare payments, regardless of outlier or transitional pass-through payments. Some facilities will fare better than others, including acute care facilities and certain rural hospitals. Urban hospitals in general lost headway with this rule.
The winners:

• Acute care facilities, with a 3.7 percent payment increase

• Sole community hospitals in rural areas, with a 7.1 percent hike.
The losers:

• Lowest-volume urban hospitals (0-99 beds), with a 5.4 percent decrease

• Rural hospitals that have fewer  than 50 beds, with a 1.6 percent decrease.
Cover costs with radiopharmaceuticals:

For most drugs, instead of earning 83 percent of the average wholesale price in 2005, 2006 changes the reimbursement to 106 percent of the manufacturer’s average sales price (ASP).
Hint: Because CMS didn’t have enough data on radiopharmaceuticals’ costs, payment for these drugs will depend on the costs that show up in your charges. Make sure you’re charging accurately, because CMS will update these payments every quarter--and you have a say.
• Motion to warn could mean axed Medicaid cuts

Just as the much-debated budget reconciliation bill is under consideration in the Senate, an influential hospital organization and a senator took a last stand against the legislation’s provisions for Medicaid “benefit flexibility” and cost-sharing--and they won.
The American Hospital Association wrote a letter to the Senate Finance Committee and the Energy and Commerce Committee chairs stating that many safety-net providers and the patients they serve “would be especially at risk if states were to impose new cost-sharing on Medicaid recipients, make premiums and co-payments [...]

- Published on 2006-01-20