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OPPS Proposed Rule In Brief

This article was originally published in The Gray Sheet

Executive Summary

Outlier threshold tightened: CMS takes steps to "redirect outlier payments from lower-cost and relatively simple procedures to more complex, expensive procedures," according to the 2005 hospital outpatient prospective payment system proposed rule. The agency would require the cost of the service to be 1.5 times the APC payment rate and surpass the sum of the APC rate plus a $625 fixed-dollar threshold. CMS' action arises from a Medicare Payment Advisory Commission recommendation that the outlier policy be eliminated due to misuse of payments intended for high-cost cases (1"The Gray Sheet" Jan. 19, 2004, p. 14). AdvaMed and the American Hospital Association support the proposal...
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