On Friday, July 16, the 2023 Hospital Outpatient Prospective Payment System (HOPPS) proposed rule was released by the Centers for Medicare and Medicaid Services (CMS). CMS proposes a payment rate update in the outpatient setting of 2.7%, and while this is positive news, especially when compared to the Medicare Physician Fee Schedule, the fundamental flaws of the underlying payment methodologies within the HOPPS have not been addressed. Specifically, these methodologies do not recognize the distinct process of care and component coding associated with radiation therapy, and ASTRO has found that this causes radiation therapy services to be undervalued, particularly brachytherapy.
Other proposals of interest to the radiation oncology community are modest changes to the payment rates of traditional radiation oncology ambulatory payment classifications (APCs), as well as comprehensive APCs (C-APCs). Also, the two-times rule exception, which requires that the highest calculated cost of an individual procedure categorized to any given APC cannot exceed two times the calculated cost of the lowest-costing procedure categorized to that same APC, would now include APC 5611, Level 1 Therapeutic Radiation Treatment Preparation.
Next, CMS is seeking comments on a specific payment approach they might use for “software as a service (SaaS),” which are algorithm-driven services that assist practitioners in making clinical assessments. The Agency also proposes to continue the payment policy for therapeutic radiopharmaceuticals under the Average Sales Price (ASP) + 6% methodology.
Three applications were included for device pass-through status relevant to RO: NavSlimTM, NavPencil, and SmartClipTM, and CMS is seeking comments on whether these products meet pass-through criteria.
Finally, additional proposals in the proposed rule are related to Rural Emergency Hospitals (REH) payment policies, including REHs receiving an additional 5% payment for covered outpatient services, and REHs would also receive a monthly facility payment. CMS also proposes to pay for clinic visits furnished in excepted off-campus PBDs of the Rural Sole Community Hospitals at the full HOPPS rate.
ASTRO will submit comments to CMS later this summer. Read ASTRO’s detailed summary of the proposed rule for more.