2024 OPPS final rule: Significant updates to hospital price transparency regulations approved

Hospitals need to start preparing for major changes to price transparency requirements, according to the 2024 Outpatient Prospective Payment System (OPPS) final rule, released November 2. The final rule details a slew of changes to price transparency compliance along with reimbursement changes and updates to numerous other programs.

OPPS payments will increase by 3.1% in 2024, including a market basket update of 3.3% offset by a 0.2% productivity reduction. Although this is higher than the 2.8% CMS proposed, the American Hospital Association says it is inadequate to cover hospitals’ increased costs.

Price transparency

CMS is moving ahead with a significant overhaul of its hospital price transparency requirements, with compliance deadlines ranging from January 1, 2024, to January 1, 2025.

CMS finalized the requirement for hospitals to display their standard charge information in a machine-readable format (MRF) using a CMS template layout, data specifications, and data dictionary. Similar to CMS’ sample templates that are currently available, the templates will come in three versions: a comma-separated values (CSV) wide format, a CSV tall format, and a JSON schema.

CMS also finalized its proposals to expand and revise the data elements contained in the MRF. New and revised data elements include:

• Whether the item or service is provided as part of an inpatient admission or outpatient services
• The drug unit and type of measurement (applicable to drugs only, effective January 1, 2025)
• The estimated allowed amount for the item or service if the standard charge is based on a percentage or algorithm (effective January 1, 2025)

Hospitals will be required to include a statement in the MRF affirming that the information contained therein is accurate and complete as of the date indicated in the file.

CMS also moved ahead with numerous changes to oversight and enforcement.

Many stakeholders commented that CMS’ proposed 60-day grace period to come into compliance with the OPPS final rule would not be enough time for hospitals, particularly for the technical requirements related to updating MRFs. CMS concurred with commentors and instead finalized a phased implementation. Enforcement will be based on these specific dates.

Dental services

OPPS payment will be provided for the more than 240 dental codes to align with the 2023 Medicare Physician Fee Schedule (MPFS). The dental codes will be assigned to clinical APCs. CMS also finalized updates to dental codes assigned to APCs and coverage and payment for dental services provided at ambulatory surgical centers.

Intensive Outpatient Program

CMS finalized its proposal to create a new outpatient behavioral health program, the Intensive Outpatient Program (IOP). The IOP will bridge the coverage gap between inpatient-level care and traditional outpatient therapy. IOP services will be paid on a per-diem basis under the OPPS or other applicable payment systems if provided in, for example, a rural health clinic or Federally Qualified Health Center. The final list of codes that may be reported for these services is still being developed, according to the final rule.

Other provisions

CMS opted not to move ahead, at this time, with creating a payment for hospitals that establish a stock of essential medicines to protect against supply disruption. The agency may address this issue through changes to Conditions of Participation (CoP) and rulemaking related to hospital processes for pharmaceutical supply.

CMS did finalize changes to the partial hospitalization program rate setting and per-diem rates, as well as to the community mental health centers’ CoPs. Other changes include:

• Payment for remote mental health services
• Payment for Indian Health Services and Tribal facilities that convert to rural emergency hospitals
• Device pass-through payment
• Quality reporting programs

Conclusion

Revenue integrity professionals should review the final rule, paying particular attention to sections that directly affect their job duties, department, and facility. Take note of compliance and enforcement deadlines. Plan updates to systems and processes and establish a plan for auditing them in 2024 to ensure they are in compliance.

Reach out to colleagues in other departments that may be affected by various provisions of the final rule to ensure they’re aware of changes and to discuss any potential changes to workflows or systems. Coordinate education with other departments to ensure consistent messaging.

Continue to monitor CMS communications for updates on compliance and enforcement deadlines.

For additional analysis of the final rule, look for more coverage in the January 2024 issue of the NAHRI Journal and register for the webinar “Unpack the 2024 OPPS Final Rule,” presented by Kimberly A. Hoy, JD, CPC, director of Medicare and compliance for HCPro; Teri Rice, MSN, MHA, MBA, RN, CHC, lead instructor for HCPro’s Medicare Boot Camp—Critical Access Hospital Version and Rural Health Clinic Version and an instructor for the Medicare Boot Camp—Utilization Review Version; and Amy Inch, COTA, CPC, CPMA, HCPro’s Medicare Boot Camp—Physician Services Version and Denials and Appeals version.