For 2016, a hospital will be eligible for an outlier payment if its cost of furnishing a service exceeds 1.75 times the APC payment amount and exceeds the APC payment amount plus $3,250.
The payment thresholds this year (2015) are 1.75 times the APC payment amount and a fixed dollar threshold of $2,775.
If the cost of a service exceeds both the multiplier threshold and the fixed-dollar threshold, the outlier payment is calculated as 50 percent of the amount by which the cost of furnishing the service exceeds 1.75 times the APC payment amount.
- The OPPS drug cost packaging threshold will be $100 for 2016 — if the estimated per day cost of a non-pass through drug or biological is equal to or less than $100 it will not be paid separately but rather packaged into the procedure.
- All diagnostic radiopharmaceuticals, non-pass through drugs and biologicals that function as supplies when used in a surgical procedure or diagnostic test or procedure will continue to be fully packaged.
- Beneficiary co-payments will remain at around 20%. Actual copays per CPT and HCPCS code can be found in Addendums A and B in the final rule.
- CMS will restructure nine of its APC groupings to “improve clinical homogeneity, improve resource homogeneity, reduce resource overlap with other APCs, and simplify and improve the OPPS APC structure.”
