Recently, the Centers for Medicare & Medicaid Services (CMS) announced several updates to payment rates and policies in the 2022 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule. With these updates, CMS aims to continue bolstering safe and effective patient care and increase price transparency.  

Quality reporting changes are coming as well—something anticipated for several years now—as the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey will become a mandatory measure in the Hospital Outpatient Quality Reporting Program beginning in January 2024 and the ASC Quality Reporting Program starting in January 2025. Hospital outpatient departments (HOPDs) and ASCs that don’t comply are subject to an annual rate reduction in their Medicare payments. In addition, web-based (digital) surveying will be allowed for OAS CAHPS for the first time starting in 2022, meaning facilities will soon be able to send emailed or mailed invitations to web-based OAS CAHPS surveys with either mail or phone follow-up to nonrespondents. Press Ganey will discuss both OAS CAHPS developments in a Dec. 8 webinar

New Guidance for Outpatient Settings in 2022 and Beyond

What follows are several additional key updates for HOPDs and ASCs. For more details and a complete account of all CMS updates, see the final rule

Annual Rate Increase and Pandemic-Adjusted Rate-Setting

OPPS providers and ASCs that meet quality reporting requirements in 2022 will continue to be awarded for their efforts by CMS, which will increase their Medicare payment rates by 2%. This is an estimated $5.9 billion year-over-year rise for OPPS providers, and a $40 million increase for ASCs. However, facilities that fail to meet the requirements will face a 2% rate reduction in payments. To ensure fairness in rate-setting for 2022, CMS won’t use 2020 claims and cost data, owing to the significant effect of the pandemic on outpatient services. Instead, 2019 data is being used.  

Likewise, 2019 claims data will be used to set rates for services provided by outpatient departments and community mental health centers in the Partial Hospitalization Program, owing to a significant reduction in the number of PHP days in 2020.  

Finally, also due to the effects of the pandemic, CMS will provide up to four quarters of separate payment for 27 drugs and biologicals and one device category whose pass-through payment status will expire between Dec. 31, 2021, and Sept. 30, 2022.  

IPO List Elimination Reversal and Other Patient Safety-Centered Updates

For 2022, CMS will pause the elimination of the IPO list due to concerns about patient safety. The list covers services that, due to their medical complexity, Medicare will only pay for when performed in the inpatient setting. Most of the 267 services removed in 2021 will be added back. CMS will reinstate criteria from 2020 for additions to the ASC Covered Procedures List and begin a nomination process in 2023. 

CMS also took steps to alleviate any financial incentives to use potentially harmful opioids instead of non-opioid alternatives for pain management. In order to qualify for separate payment in the ASC setting, certain non-opioid alternatives must face new application approval or licensing, have an FDA-approved indication for pain management or analgesia, and meet an OPPS drug packaging threshold.  

Radiation Oncology Model to Begin Soon

The Radiation Oncology (RO) model, which had been delayed due to the pandemic, will begin Jan. 1, 2022. The five-year model aims to improve care quality for cancer patients receiving radiotherapy and move toward a simpler payment system. Model participation is mandatory for certain providers, whose Medicare payments for radiotherapy services to treat specific types of cancer are impacted by performance on a set of quality measures. The model will include an “extreme and uncontrollable circumstances” (EUC) policy, which CMS intends to invoke for performance year one (Jan. 1 through Dec. 31, 2022). With the EUC in play, quality measurement and other model requirements will be optional during PY1 and the 2% quality withhold will not be applied to RO model professional episode payments.   

Promotion of Clarity on What Hospitals Bills Actually Cover

Confusion over how much services and items cost when furnished in a healthcare setting is an ongoing problem, but the 2022 final rule attempts to help solve it by increasing larger hospitals’ sanctions for non-compliance with existing price transparency requirements. While smaller hospitals with 30 beds or fewer will face the same $300 minimum civil monetary penalty per day for noncompliance, larger hospitals will see an increase to $10 per bed per day, not to exceed a maximum daily amount of $5,500.  

Further changes in the final rule address simplification of how Medicare beneficiaries’ required coinsurance is calculated for colorectal cancer screening. If a patient undergoes a screening test for colorectal cancer (colonoscopy or flexible sigmoidoscopy), that coinsurance amount will be determined by viewing all surgical services performed on the same date as the screening test as part of the same clinical encounter.  

Complying with the OAS CAHPS Mandate and Diving Deeper

With its history as a CMS-approved OAS CAHPS vendor, Press Ganey is primed to help healthcare organizations unfamiliar with this measurement tool integrate the new surveying requirement into overall measurement and engagement strategies. With ASCs and HOPDs in the top 10% of the Press Ganey OAS CAHPS database improving their overall facility rating up to 15.2% from 2019 to 2020, our improvement experts are positioned to help you turn insights into outcomes in this competitive and emerging care setting. And after administering 395 million digital surveys in 2020, we’re further prepared to support transitions to this new delivery method by helping you master patient email capture workflows with best practices and tracking mechanisms so you can understand and act on patient needs at the most granular levels of your organization. To learn more, register for the upcoming webinar with top Press Ganey experts.