HFMA comments to CMS on the 2015 Medicare OPPS Proposed Rule

August 29, 2014

Marilyn Tavenner
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS–1613–P
P.O. Box 8013
Baltimore, MD 21244-1850

File Code: CMS–1613–P

Re: Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Physician-Owned Hospitals: Data Sources for Expansion Exception; Physician Certification of Inpatient Hospital Services; Medicare Advantage Organizations and Part D Sponsors: Appeals Process for Overpayments Associated With Submitted Data; Proposed Rule

Dear Ms. Tavenner:

The Healthcare Financial Management Association (HFMA) would like to thank the Centers for Medicare & Medicaid Services (CMS) for the opportunity to comment on the 2015 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Physician-Owned Hospitals: Data Sources for Expansion Exception; Physician Certification of Inpatient Hospital Services; Medicare Advantage Organizations and Part D Sponsors: Appeals Process for Overpayments Associated With Submitted Data; Proposed Rule (hereafter referred to as the 2015 OPPS Proposed Rule) published in the July 14, 2014, Federal Register. 

HFMA is a professional organization of more than 40,000 individuals involved in various aspects of healthcare financial management. HFMA is committed to helping its members improve the management of and compliance with the numerous rules and regulations that govern the industry.  

Introduction

HFMA would like to commend CMS for its thorough analysis and discussion of the myriad Medicare hospital reimbursement decisions addressed in the 2015 OPPS Proposed Rule. Our members have significant concerns regarding the proposals related to:  

• Add an additional quality measure to both the outpatient and ASC quality reporting programs for colonoscopies (OP-32/ASC-12) for 2017 payment determination
• Remove OP-31/ASC-11 from the CY 2016 payment determination and allow hospitals and ASCs to voluntarily report for the CY 2017 payment determination
• Continue payment policies for hospital outpatient clinics and emergency department visits
• Collect data on services furnished in off-campus provider based departments

Proposed Addition of OP–32: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy for the CY 2017 Payment Determination and Subsequent Years

CMS proposes to add OP–32/ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy for the CY 2017 payment determination and subsequent years for both the OPQR and ASCQR. OP-32/ASC-12 measures all cause, unplanned hospital visits (admissions, observation stays, and emergency department visits) within 7 days of an outpatient colonoscopy procedure. The measure is conditionally supported by the MAP, however the MAP has recognized the need for the measure to be further developed and gain NQF endorsement. Specifically there are concerns about the reliability and validity of the measure, as well as with the accuracy of the algorithm for attributing claims data in light of possible effects of the Medicare 3-day payment window policy. CMS states in the proposed rule it believes it has resolved these issues. 

HFMA agrees with CMS that OP-32/ASC-12 represents an important area to monitor for quality improvement given the number of procedures performed annually. However, we have significant concerns with this measure for use in both the outpatient and ASC setting. 

First, we believe OP-32/ASC-12 should be refined to only measure potentially preventable adverse events associated with colonoscopies instead of all cause unplanned hospital visits. CMS states in the proposed rule the range of potentially preventable adverse events is “well-described”, and lists a series of conditions/procedures that are generally indicative of quality issues related to colonoscopies. This list includes: repeat procedures, or surgical intervention for treatment, including colonic perforation, gastrointestinal (GI) bleeding, and cardiopulmonary events such as hypoxia, aspiration pneumonia, and cardiac arrhythmias. HFMA believes that any measure of potentially preventable adverse events be limited to the preventable adverse events associated with a procedure, otherwise CMS runs the risk of measuring and publicly reporting random events that are not potentially preventable or related to a given procedure. Therefore, HFMA believes the measure OP-32/ASC-12 should be limited to the list of potentially preventable adverse events listed in the proposed rule.

Second, this measure has not been endorsed by the NQF. HFMA, as it has stated in prior comment letters related to other measures, believes that all measures should be endorsed by the NQF.  

Removal of OP-31/ASC-11 from the CY 2016 Payment Determination and Allow Hospitals and ASCs to Voluntarily Report for the CY 2017 Payment Determination

Given the operational challenges both hospitals and ASCs have encountered collecting and reporting OP-31/ASC-11, HFMA supports CMS’s decision earlier this year to remove the measure from the CY payment determination. Further, HFMA supports CMS’s proposal in the 2015 proposed rule to make collection and submission of this measure voluntary. We appreciate CMS listening to feedback from industry stakeholders and making these changes. 

Payment for Hospital Outpatient Clinics and Emergency Department Visits

For the CY 2014 rule, CMS finalized its proposal to collapse five levels of outpatient clinic visit (each with its own CPT code) into one HCPCS code. CMS proposed to continue this policy for CY 2015. In its comment letter regarding the CY 2014 proposed rule, HFMA’s members strongly disagreed with this proposal. As stated in the comment letter, HFMA remains concerned about the potential for inappropriate revenue redistribution if CMS elects to continue this policy as proposed. Under the averaging mechanism that CMS has outlined in the proposed rule, hospitals that see more complex clinic visits will be financially harmed while providers that see less complex cases will benefit financially without any change in the underlying health of the patient populations served. As such, HFMA recommends reverting back to the policy prior to the CY 2014 final rule which allowed for five levels of outpatient clinic visit based on the patient’s severity to ensure that providers are appropriately paid for the services they provide to complex patients.

Also in the CY 2014 rule, CMS proposed a similar policy for emergency department visits. However, it opted not to finalize the proposal. In the 2015 proposed rule, CMS proposes to continue billing for ED visits using five separate CPT codes that reflect patient severity. For the reasons stated above regarding the potential for hospitals that see more complex patients to be underpaid for their services, HFMA strongly supports CMS’s proposal regarding ED visits.  

Collecting Data on Services Furnished in Off-Campus Provider Based Departments

CMS, seeks to understand how the growing trend toward hospital acquisition of physician offices and subsequent treatment of those locations as off-campus provider based outpatient departments affects payments under the MPFS and OPPS, as well as beneficiary cost-sharing obligations. To do so, in the CY 2015 proposed rule, CMS has proposed to create a HCPCS modifier to be reported with every code for physicians’ services and outpatient hospital services furnished in an off-campus provider based department of a hospital on both the CMS–1500 claim form for physicians’ services, and the UB–04 form (CMS Form 1450) for hospital outpatient services. 

HFMA is concerned that the potential Medicare-only information collection approach would create additional administrative burden for hospitals and physicians, and would result in inconsistent billing approaches between Medicare and non-Medicare payers. However, HFMA believes that if CMS is intent on collecting this information, its proposal to add a HCPCS modifier applicable to both hospital and physician claims is the least burdensome.

Further, HFMA urges CMS to refrain from using the information it collects as a means to justify implementing “site-neutral” payment reductions, such as the policies that MedPAC and Congress have pursued in the context of federal budget cuts. Instead, CMS should recognize the trend towards greater physician integration with hospitals reflects efforts by hospitals and health systems to provide more coordinated care delivery that focuses on appropriate utilization, efficiency, and outstanding measureable outcomes. HFMA believes that CMS should work with the provider community to determine the best way to evaluate differences in cost and service patterns. The agency must fully understand the role off-campus provider-based departments play in ensuring access to quality care for beneficiaries. CMS must be transparent on exactly how the measure data collected will be used to inform payment policy. 

HFMA looks forward to any opportunity to provide assistance or comments to support CMS’s efforts to refine and improve the 2015 OPPS Proposed Rule. As an organization, we take pride in our long history of providing balanced, objective financial technical expertise to Congress, CMS, and advisory groups. We are at your service to help CMS gain a balanced perspective on this complex issue. If you have additional questions, you may reach me or Richard Gundling, Vice President of HFMA’s Washington, DC, office, at (202) 296-2920. The Association and I look forward to working with you.

Sincerely,

Joseph J. Fifer, FHFMA, CPA
President and Chief Executive Officer
Healthcare Financial Management Association 

About HFMA

HFMA is the nation’s leading membership organization for more than 40,000 healthcare financial management professionals. Our members are widely diverse, employed by hospitals, integrated delivery systems, managed care organizations, ambulatory and long-term care facilities, physician practices, accounting and consulting firms, and insurance companies. Members’ positions include chief executive officer, chief financial officer, controller, patient accounts manager, accountant, and consultant.

HFMA is a nonpartisan professional practice organization. As part of its education, information, and professional development services, HFMA develops and promotes ethical, high-quality healthcare finance practices. HFMA works with a broad cross-section of stakeholders to improve the healthcare industry by identifying and bridging gaps in knowledge, best practices, and standards.