On September 9, 2021, the Centers for Medicare & Medicaid Services (CMS) posted new information on reprocessing claims for outpatient clinic visit services provided at excepted off-campus provider-based departments (PBDs).
By November 1, 2021, CMS will begin reprocessing claims for outpatient clinic visit services provided at excepted off-campus PBDs so they are paid at the same rate as non-excepted off-campus PBDs for those services under the Medicare Physician Fee Schedule (PFS).
This affects certain claims with dates of service between January 1 - December 31, 2019. CMS will reprocess all affected claims. Providers must refund the coinsurance difference to patients (or payers) who paid the higher coinsurance rates based on new remittance advice information.
Why is CMS reprocessing these claims at a lower reimbursement rate?
On November 21, 2018, the 2019 Hospital Outpatient Prospective Payment System (OPPS) rule finalized payment for certain outpatient clinic visit services provided at excepted off-campus PBDs at the same rate that CMS pays non-excepted off-campus PBDs for those services under the PFS. CMS phased in this change and in 2019 reduced payment to 70% of the full OPPS rate in off-campus PBDs and in 2020, this rate changed to 40%.
On September 17, 2019, the U.S. District Court for the District of Columbia declared invalid the 2019 payment rule that provided for the reduction for clinic visits provided at excepted off-campus PBDs. From January 1 to July 2020 CMS reprocessed calendar year 2019 claims paid at the reduced payment rate of 70% to restore the 100% payment rate in accordance with the district court decision.
On July 17, 2020, the U.S. Court of Appeals for the D.C. Circuit reversed the district court ruling, upholding CMS’ site-neutrality payment policy for off-campus outpatient hospital clinic visits. The U.S. Supreme Court subsequently declined to hear the case.
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