BETHESDA, MD 30 Dec 2013—Reimbursement rates under
Medicare for drugs provided by hospitals in the outpatient setting in 2014 will
continue at the 2013 rate—the average sale price (ASP) of the drug
reimbursement rate, published in the December 10 Federal Register,
appears in the Centers for Medicare and Medicaid Services (CMS) final rule for
the 2014 Medicare hospital outpatient prospective payment system (OPPS).
ASP-plus-6% rate applies to drugs and biologics that are not bundled within an ambulatory payment
classification (APC) group because their
average cost per day of treatment exceeds $90 (in 2013, the threshold cost was
$80). CMS refers to these as "separately payable" drugs.
ASP-plus-6% reimbursement rate also applies to the 26 products that have what
CMS calls "transitional pass-through" status. Pass-through products
are new, high-cost products whose reimbursement rate is set by statute for a
period of two to three years (see table).
reimbursed at ASP plus 6% are therapeutic radiopharmaceuticals and clotting
factors. CMS will continue to pay a "furnishing fee" for clotting
factors of $0.192 per unit, up from $0.188 per unit in 2013.
CMS estimated that the changes in the OPPS will result in a 1.7% overall increase
in payments to participating hospital outpatient departments during 2014. In
all, the agency expects OPPS expenditures to total $50.4 billion during 2014.
Packaged reimbursement. The 2014 final rule brings a major
expansion to the list of so-called policy-packaged products and services,
which, unless they have pass-through status, are bundled into APC groups and
not reimbursed separately.
of policy- packaged products include diagnostic radiopharmaceuticals and
contrast agents, which were first bundled into APC groups in 2008.
As of January 1, "drugs, biologicals, and
radiopharmaceuticals that function as supplies when used in a diagnostic test
or procedure and drugs and biologicals that function as supplies when used in a
surgical procedure" are also packaged into APC groups, according to CMS.
Topoleski, ASHP's director of federal regulatory affairs, said the revised
packaging policy reflects CMS's shift away from fee-for-service reimbursement
and is similar to the agency's reimbursement philosophy for inpatient care
He said that ASHP does not oppose the APC-group
packaging policy, provided that it incorporates "the full costs associated
with these biologicals and radiopharmaceuticals, including pharmacy overhead
and handling costs, and acknowledgment of the resource-intensive nature of
certain categories of drugs."
Incident-to billing. The final rule clarifies that, as a
condition of participation in Medicare, therapeutic services provided by
nonphysician health care practitioners and billed incident to a physician's
care must occur in accordance with state law. This means that health care providers who perform these services
must be appropriately licensed by their state and must abide by the state's
scope-of-practice laws and regulations.
to the final rule, CMS has learned of instances in which Medicare was billed
for incident-to services that were provided by practitioners who did not meet
their state's requirements for performing the services, although the
supervising physician was qualified to perform them.
indicated that it had limited recourse to withhold payment in these situations
because compliance with state law was not, at the time, an explicit requirement
final rule also ends CMS's policy of "enforcement instruction" for
critical access and small rural hospitals, which had previously been exempt
from direct-supervision requirements for incident-to services. Starting in
2014, all outpatient therapeutic services except those specifically designated
by CMS as requiring general supervision must be provided under the direct
supervision of an appropriate physician or nonphysician provider.
Vaccine administration, certain infusion-related services, and smoking-cessation counseling remain under Medicare's
general supervision requirements.
Quality reporting. The final rule adds to the Hospital
Outpatient Quality Reporting Program four National Quality Forum–endorsed
quality reporting measures. One measure tracks influenza vaccination rates of
health care providers, and the others pertain to colonoscopy or cataract
fully supports this quality measure," Topoleski said of the influenza
vaccination reporting requirement.
ASHP policy 0615 calls for influenza vaccination for all
health care workers, with exemptions for medical contraindications, religious
obligations, and informed declination.