Pharmacy News

OPPS Continues ASP-Plus-6% Reimbursement Rate for 2014

[January 15, 2014, AJHP News]

Kate Traynor

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 plus 6%.

The 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).

The 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.

The 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).

Also 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.

Examples 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.

Christopher 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 services.

Christopher Topoleski

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.

According 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.

CMS 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 under OPPS.

The 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 surgery.

"ASHP 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.


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