2024 OPPS proposed rule: Major changes to price transparency requirements, covered services, and reimbursement

Wednesday, July 19, 2023

CMS is doubling down on price transparency compliance and enforcement, according to the 2024 Outpatient Prospective Payment System (OPPS) proposed rule. The proposed rule, released July 13, details major changes to price transparency requirements and also proposes numerous changes to behavioral health reimbursement, coverage of dental services, and more.

Payment rates

CMS is proposing a 2.8% increase to OPPS payments for hospitals that meet quality reporting requirements. Ambulatory surgical centers would see a productivity-adjusted increase of 2.8%, according to the proposed rule.

Citing lessons learned from the COVID-19 public health emergency, CMS is asking for comments on providing a separate payment under the Inpatient Prospective Payment System (IPPS) for hospitals to establish and maintain a stock of essential medicines. This potential payment would be for cost reporting periods as soon as January 1, 2025, and an adjustment under the OPPS may be considered in the future.

Hospital price transparency

Some of the most significant proposals center on hospital price transparency requirements. CMS is proposing a significant overhaul to the requirements hospitals would have to comply with as well as how it enforces compliance.

Currently, hospitals are required to post a list of their standard charges in a machine-readable file (MRF). They are also required to post a list of their charges for 300 shoppable services, as defined by CMS, or make available a price estimator tool. Although CMS has published sample templates hospitals may use for their MRF, it currently does not require the use of a specific form or format.

CMS is proposing to require hospitals to use a CMS template. The template would be released in three versions: a CSV “wide” format, a CSV “tall” format, and a JSON schema.

The agency is also proposing to require hospitals to encode standard charge information that corresponds to required data elements, according to the proposed rule. This may include:

  • General data. This could include hospital license number, and location name and address at which the items and services may be obtained at the charge listed in the MRF.
  • Types of standard charges (e.g., payer-specific negotiated charges). This may include data such as the payer and plan name as stated in the specific contract, the contracting method used to determine the standard charge, and how the standard charge should be interpreted.
  • Description of the item or service. This would include information such as the drug unit and type of measurement, whether the item or service is associated with inpatient or outpatient services, and more.
  • Codes. This may include any codes used for billing and would include modifiers and the type of code (e.g., HCPCS).

CMS would begin enforcing use of the template 60 days after the effective date of the 2024 OPPS final rule; in other words, on March 1, 2024.

“Although I am not surprised at all with the proposed changes related to hospital price transparency regulations, I am quite shocked that CMS believes that hospitals can produce and publish files in one of the proposed required template formats within 60 days of the effective date of the 2024 final rule,” says NAHRI Advisory Board member John Settlemyer, MBA, MHA, CPC, CHRI, assistant vice president of enterprise revenue management/CDM operations at Atrium Health in Charlotte, North Carolina.

“In addition to formulating thoughtful and detailed comments on all the hospital price transparency proposed revisions, every hospital in the country should demand that CMS allow, at minimum, one year to come into compliance with any new hospital price transparency policies finalized in the 2024 OPPS final rule,” he added.

CMS is proposing that hospitals validate the data elements. The validation would consist of an affirmation from an authorized hospital official that the MRF is accurate and complete and would be contained in the MRF. A message on the hospital’s website or other explanatory language would not be considered sufficient.

“This requirement was largely brought about due to findings in enforcement activities, and questions from the public, when data cells were left blank or indicated with ‘N/A,’ for example, with the cash prices,” says NAHRI Advisory Board member Caroline Znaniec, MBA, MS-HCA, CRIP, managing director of healthcare business performance improvement at Protiviti.

CMS is proposing to require hospitals to include a footer at the bottom of the hospital’s homepage that includes a link to the page where the MRF can be found. It’s also proposing to require that hospitals include a .txt file in the root folder of the site used to host the MRF. The .txt file would include the URL for the MRF and the publicly available page that includes the link to the MRF. These requirements are largely aimed at improving accessibility for third-party automated services and data aggregators that provide services to help the public understand that data contained in the MRF, Znaniec explains.

“CMS does not expect the financial impact of implementing the proposed changes to be minimal to hospitals,” Znaniec says.

In the proposed rule, CMS estimates that the proposals to enhance automated access to and aggregation and use of MRFs will cause increased burden on hospitals and result in a one-time average of $2,787 per hospital. The agency maintains that the increased burden and costs will be outweighed by the benefits to the public and to hospitals themselves.

CMS is proposing a number of changes to its enforcement activities. These proposals would require hospitals to acknowledge receipt of a noncompliance warning in the format and by the date specified in the warning, require health system leadership to work with individual hospitals in the system when one or more is noncompliant, and make other changes to how hospitals monitor for compliance. The agency is also proposing to publicize information related to compliance assessments, compliance actions taken against hospitals, and notifications sent to health system leadership.

In addition, CMS is seeking feedback on how it can bring its hospital price transparency requirements into alignment with the Transparency in Coverage Act and the No Surprises Act.

New outpatient program

CMS is proposing to establish a new program and benefits for behavioral health, the Intensive Outpatient Program (IOP), as required by the Consolidated Appropriations Act of 2023. According to the proposed rule, the IOP would be a distinct outpatient psychiatric program available to hospital outpatient departments, community mental health centers (CMHC), Federally Qualified Health Centers (FQHC), and rural health clinics (RHC). Payment would be made on a per-diem basis under the OPPS or other applicable payment system. The payment calculation would be based on OPPS data that includes partial hospitalization program (PHP) and non-PHP days.

CMS is proposing to create two IOP APCs—one for days with three services per day and one for days with four or more services per day.

Dental services

CMS is proposing OPPS payment for 230 dental codes to align with the 2023 Medicare Physician Fee Schedule final rule. These codes would be assigned to clinical APCs. It’s also proposing to add 26 separately payable dental surgery procedures to the ASC covered procedures list and 78 ancillary dental services to the list of covered ancillary procedures.

The proposed expansion of dental coverage is important, but organization will need to keep in mind that it’s limited in scope, says NAHRI Advisory Board member Ronald Hirsch, MD, FACP, CHCQM, CHRI, vice president, regulations and ethics group with R1 RCM Inc.

“It will be crucial that these services are only provided to patients who meet the qualifications and that there is appropriate documentation,” he says.

Organizations may also find it challenging to find dentists that are willing to perform the services at hospitals for Medicare payment rates, which are likely lower than the payment they receive in their offices, Hirsch adds.

Other proposals and requests for comments

CMS is proposing numerous other changes such as changes to rural emergency hospital reimbursement, quality reporting, pass-through devices, and more. The agency is also requesting comments on payment for high-cost drugs and services out of the Indian Health Services all-inclusive rate and payment for diagnostic radiopharmaceuticals when the cost exceeds payment of the test.

Next steps

Revenue integrity professionals should read the rules thoroughly. Pay particular attention to proposals that may directly affect your organization and the services it offers. Reach out to colleagues in other departments, such as compliance, HIM, finance, IT, or CDI, to discuss proposals that would impact them and their workflows. Consider how proposals may be beneficial or detrimental to Medicare beneficiaries and what effect they might have on your local healthcare community. In some cases, it may be helpful to model financial impacts and hold preliminary meetings, for example, with IT to discuss the technical aspects of CMS’ price transparency proposals, to understand what resources would be necessary to comply.

Finally, revenue integrity professionals are strongly encouraged to submit comments on the proposed rule. As NAHRI Advisory Board member Jugna Shah, MPH, CHRI, president of Nimitt Consulting, Inc., points out, CMS does take comments into consideration and will respond to data-driven feedback. For tips on how to write and submit comments on proposed changes, read NAHRI’s white paper Advocacy in Action: Commenting on Proposed Rules. Comments on the proposed rule are due September 11.