Healthcare News & Insights

Proposed rule updates hospital outpatient payment policies

A proposed rule updates hospital outpatient payment policies and rates. Will it affect your facility?

New changes in Medicare payment and policies could affect more than 4,000 hospital outpatient departments (HOPDs) and approximately 5,000 Medicare-participating ambulatory surgical centers (ASCs).

The Centers for Medicare & Medicaid Services recently issued a proposed rule centered around these two aspects of healthcare that would take effect on Jan. 1, 2013.

The first component of this new rule relates to payment rates. CMS has proposed to increase HOPD rates by 2.1% and ASC payment rates by 1.3%. These increases are based on the projected inflation rate for goods and services used by hospitals, for HOPDs, and the consumer price index for urban consumers, for ASCs.

Based on the proposed increase in payment rates, CMS predicts the total payments in 2013 will be $48.1 million to hospitals and $4.1 billion to ASCs.

The proposed rule also aims to improve outpatient care policies, making Quality Improvement Organizations (QIOs) more responsive to beneficiary complaints about quality of care.


It would provide beneficiaries with more information about the QIO’s review process and establish a dispute resolution option called Immediate Advocacy to resolve any complaints. Second, the rule would give QIOs the authority to send and receive electronic versions of health information. Finally, the proposed rule would permit QIOs to release more information about the results of their reviews to beneficiaries.

The proposed rule would also make changes to quality reporting programs for HOPDs, ASCs and Inpatient Rehabilitation Facilities. Although not seeking to add measures for payment determination, CMS proposes reporting for 23 measures for the CY2014 payment determination and 24 measures for the CY2015 payment determination.

Finally, the rule contains proposals relating to retirement and retention of HOPD regulations. Some specific features of this part of the rule include adopting updates on a previously adopted measure, adopting a policy that would ensure that any previously adopted measure will remain in effect unless it is replaced, removed or suspended, and adopting policies regarding when notice-and-comment rulemaking will be permitted.

CMS hopes these rules will give beneficiaries the ability to take a more active role in the QIO review process. It also hopes they will promote a quicker resolution of quality complaints.


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