CY 2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS 1772-P)
On July 15, 2022, the Centers for Medicare & Medicaid Services (CMS) proposed Medicare payment rates for hospital outpatient and Ambulatory Surgical Center (ASC) services. The calendar year (CY) 2023 Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule is published annually and will have a 60-day comment period, which will end on September 13, 2022. The final rule will be issued in early November.
In addition to proposing payment rates, this year’s rule includes proposals that align with several key goals of the Administration, including advancing health equity in rural areas, promoting competition in the health care system, and promoting safe, effective, and patient-centered care. The proposed rule would further the agency’s commitment to strengthening Medicare and use the lessons learned from the COVID-19 PHE to inform the approach to quality measurement.
The proposed policies will affect 3,411 hospitals and approximately 5,500 ASCs. CMS is publishing this proposed rule to meet the legal requirements to update Medicare payment policies for OPPS hospitals and ASCs on an annual basis. This fact sheet discusses the major provisions of the proposed rule (CMS-1772-P), which can be downloaded at: https://www.federalregister.gov/documents/current
Updates to OPPS and ASC payment rates
In accordance with Medicare law, CMS is proposing to update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.7%. This update is based on the projected hospital market basket percentage increase of 3.1%, reduced by 0.4 percentage point for the productivity adjustment.
In the CY 2019 OPPS/ASC final rule with comment period, CMS finalized the proposal to apply the productivity-adjusted hospital market basket update to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023). Using the proposed hospital market basket update, CMS is proposing to update the ASC rates for CY 2023 by 2.7%. The proposed update applies to ASCs meeting relevant quality reporting requirements. This update is based on the projected hospital market basket percentage increase of 3.1%, reduced by 0.4 percentage point for the productivity adjustment.
Rural Emergency Hospitals: Payment Policies
There has been a growing concern that closures of rural hospitals and critical access hospitals (CAHs) are leading to a lack of services for people living in rural areas. Section 125 of the Consolidated Appropriations Act, 2021 (CAA) established a new Medicare provider type called Rural Emergency Hospitals (REHs), effective January 1, 2023.
REHs are facilities that convert from either a CAH or a rural hospital (or one treated as such under section 1886(d)(8)(E) of the Social Security Act) with less than 50 beds, and that do not provide acute care inpatient services with the exception of skilled nursing facility services furnished in a distinct part unit. On June 30, 2022 CMS published a rule proposing the Conditions of Participation (CoPs) for Rural Emergency Hospitals. In this rule, CMS is proposing the provider enrollment procedures and payment rates that would apply to REHs. Together, the policies in these proposed rules will allow rural hospitals to seek this new designation and provide continued access to emergency services, observation care, and additional medical and outpatient services.
By statute, REH services include emergency department services, observation care, and may include other outpatient medical and health services as specified by the Secretary. Covered outpatient department services provided by REHs will receive an additional 5% payment for each service. Beneficiaries will not be charged coinsurance on the additional 5% payment. REHs will also receive a monthly facility payment. After the initial payment is established in CY 2023, the payment amount will increase in subsequent years by the hospital market basket percentage increase.
To improve access to all types of care in rural settings, CMS is proposing to consider all covered outpatient department services (that is, services that would otherwise be paid under the OPPS) as REH services. REHs would be paid for furnishing REH services at a rate that is equal to the OPPS payment rate for the equivalent covered outpatient department service increased by 5%. CMS is also proposing that REHs may provide outpatient services that are not otherwise paid under the OPPS (such as services paid under the Clinical Lab Fee Schedule) as well as post-hospital extended care services furnished in a unit of the facility that is a distinct part of the facility licensed as a skilled nursing facility; however, these services will not be considered REH services and, therefore, will be paid under the applicable fee schedule for such services and will not receive the additional 5% payment increase that CMS proposes to apply to REH services.
Rural Emergency Hospital (REH) Provider Enrollment
Providers and suppliers are required to enroll in Medicare to receive payments for services and items furnished to Medicare beneficiaries. The purpose of the provider enrollment process is to help confirm that providers and suppliers seeking to bill Medicare meet all federal and state requirements to do so. This proposed rule would update our existing Medicare provider enrollment regulations in 42 CFR Part 424, subpart P, to address enrollment requirements for REHs. (Additional information regarding these requirements is included in the proposed rule’s preamble as well as in future sub-regulatory guidance.) One of the most important REH enrollment provisions in the proposed rule is that the facility may submit a Form CMS-855A change of information application (rather than an initial enrollment application) in order to convert from a CAH to an REH. We believe that not requiring an initial application, which generally takes longer for a Medicare Administrative Contractor (MAC) to process than a change of information application, would help expedite the CAH-to-REH conversion.
Rural Emergency Hospitals Physician Self-Referral Law Update
The physician self-referral law, commonly known as the “Stark Law”: (1) prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship, unless the requirements of an applicable exception are satisfied; and (2) prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third-party payer) for any improperly referred designated health services. A financial relationship may be an ownership or investment interest in the entity or a compensation arrangement with the entity. The statute establishes a number of specific exceptions and grants the Secretary the authority to create regulatory exceptions for financial relationships that do not pose a risk of program or patient abuse.
In the CY 2023 OPPS/ASC proposed rule, CMS is proposing updates to the physician self-referral law for the new REH provider type. Specifically, CMS is proposing (1) a new exception for ownership or investment interests in an REH; and (2) revisions to certain existing exceptions to make them applicable to compensation arrangements to which an REH is a party.
Proposed Use of June 2020 Cost Report and CY 2021 Claims Data for CY 2023 OPPS and ASC Payment System Rate Setting Due to the PHE
For the OPPS and ASC rate setting process, we use the best available data so that the payment rates accurately reflect estimates of the costs associated with furnishing outpatient services. The best available data is typically the most recent claims and cost-report data, which are usually the claims data from the CY two years prior to the year for which we are setting payment rates and cost report data from three years prior to the year for which we are setting payment rates. Consistent with our typical practice, for CY 2023 we propose to use claims data from CY 2021. However, the most recent available cost report data include periods that overlap with CY 2020. CMS believes that the CY 2020 cost report data are not the best overall approximation of expected outpatient hospital services, because half of the cost reports that typically would be used for CY 2023 rate setting have cost reporting periods that overlap with parts of the CY 2020 and would include data from the start of the PHE. In order to mitigate the impact of some of the temporary changes in hospitals' cost report data from CY 2020, CMS is proposing to use cost report data from the June 2020 Healthcare Cost Report Information System (HCRIS), which only includes cost report data through CY 2019, predating the PHE. This is the same cost report extract used to set OPPS rates for CY 2022. CMS believes using the CY 2021 claims data, with cost reports data through CY 2019 for CY 2023 OPPS rate setting, is the best approximation of expected costs for CY 2023 hospital outpatient services for rate setting purposes. As a result, CMS is proposing to use CY 2021 claims data with cost report data through CY 2019 (prior to the PHE) to set CY 2023 OPPS and ASC payment system rates.
Changes to the Inpatient Only List
Since the beginning of the OPPS, the Inpatient Only (IPO) list has defined the list of services that, due to their medical complexity, Medicare will only pay for when performed in the inpatient setting.
For CY 2023, CMS is proposing to remove ten services from the IPO list after determining that these codes meet the current criteria to remove services from the IPO list.
Changes to the ASC Covered Procedures List
The ASC Covered Procedures List (CPL) specifies the list of procedures that can be safely performed in an ASC. CMS evaluates the ASC CPL each year to determine whether procedures should be added to or removed from the list. In the CY 2023 OPPS/ASC proposed rule, CMS is proposing to add one procedure, a lymph node biopsy or excision, to the ASC CPL.
OPPS Payment for Drugs Acquired Through the 340B Program
Section 340B of the Public Health Service Act (340B) allows participating hospitals and other providers to purchase certain covered outpatient drugs from manufacturers at discounted prices. In the CY 2018 OPPS/ASC final rule with comment period, CMS reexamined the appropriateness of paying the average sales price (ASP) plus 6% for drugs acquired through the 340B Program, given that 340B hospitals acquire these drugs at steep discounts. Beginning January 1, 2018, CMS adopted a policy to pay an adjusted amount of ASP minus 22.5% for certain separately payable drugs or biologicals acquired through the 340B Program. CMS continued this policy in CYs 2019 through 2022.
The OPPS 340B policy has been the subject of litigation, recently culminating in the Supreme Court’s decision in American Hospital Association v. Becerra (No. 20-1114, 2022 WL 2135490). On June 15, 2022, the Supreme Court held that HHS may not vary payment rates for drugs and biologicals among groups of hospitals in the absence of having conducted a survey of hospitals’ acquisition costs. The Supreme Court’s decision concerned payment rates for CYs 2018 and 2019, but it has implications for CY 2023 payment rates. However, given the timing of the Supreme Court’s decision, we were unable to adjust the proposed payment rates and budget neutrality calculations to account for that decision before issuing this proposed rule. For CY 2023, we are formally proposing a payment rate of ASP minus 22.5% for drugs and biologicals acquired through the 340B Program, consistent with our prior policy. But, we fully anticipate applying a rate of ASP plus 6% to such drugs and biologicals in the final rule for CY 2023, in light of the Supreme Court’s recent decision. We are still evaluating how to apply the Supreme Court’s recent decision to prior calendar years. Impacts for both policy options are included in the addenda to the proposed rule.
Payment for Non-Opioid Products Under Section 6082 of the SUPPORT Act
The law requires that the Secretary must review payments under the OPPS and ASC for opioids, and evidence-based non-opioid alternatives for pain management, to ensure there are not financial incentives to use opioids instead of non-opioid alternatives. For CY 2023, CMS is proposing to maintain its current policy, adopted under section 1833(t)(22)(A) and section 1833(i)(8) of the Social Security Act, as added by section 6082(a) and (b), respectively, of the SUPPORT Act, to provide for separate payment for non-opioid pain management drugs and biologicals that function as supplies in the ASC setting when those products are FDA approved, have an FDA-approved indication for pain management or as an analgesic, and have a per-day cost above the OPPS drug packaging threshold, as determined by CMS.
For CY 2023, in order to ensure there are not financial disincentives to using these non-opioid pain management drugs in the ASC setting, CMS is proposing separate payment in the ASC setting for four non-opioid pain management drugs that function as surgical supplies, including certain local anesthetics and ocular drugs, that meet the criteria in 42 CFR 416.174.
Behavioral Health Services Furnished Remotely by Hospital Staff To Beneficiaries in Their Homes
For CY 2023, CMS is proposing behavioral health services furnished remotely by clinical staff of hospital outpatient departments, including staff of critical access hospitals (CAHs), through the use of telecommunications technology to beneficiaries in their homes, to be considered as covered outpatient services for which payment is made under the OPPS. Currently, this flexibility is available through the PHE-specific policy referred to as Hospitals Without Walls (HWW), but the emergency waivers that enable this flexibility will expire when the PHE for COVID-19 ends. If beneficiaries cannot continue to receive these services in their homes from hospital clinical staff, they may not be able to continue receiving behavioral health services, which may lead to loss of access to care, particularly in rural and/or underserved areas. CMS is proposing to require that payment for behavioral health services furnished remotely, to beneficiaries in their homes, may only be made if the beneficiary receives an in-person service within 6 months prior to the first time hospital clinical staff provides the behavioral health services remotely, and that there must be an in-person service, without the use of communications technology, within 12 months of each behavioral health service furnished remotely by hospital clinical staff. We are proposing to permit exceptions to the in-person visit requirement when the hospital clinical staff member and beneficiary agree that the risks and burdens of an in-person service outweigh the benefits of it, among other requirements. CMS is also proposing that audio-only interactive telecommunications systems may be used to furnish these services in instances where the beneficiary is unable to use, does not wish to use, or does not have access to two-way, audio/video technology. Audio-only communications are an important way to advance equity, since many rural and underserved communities lack stable access to broadband services, making two-way, audio/visual communication difficult.
Proposed IPPS and OPPS Payment Adjustments for Additional Costs of Domestic NIOSH-Approved Surgical N95 Respirators
The COVID-19 pandemic has illustrated how overseas production shutdowns, foreign export restrictions, or ocean shipping delays can jeopardize the availability of raw materials and components needed to make critical public health supplies. The supply of surgical N95 respirators — a specific type of filtering facepiece respirator used in clinical settings — was one type of personal protective equipment that was strained in hospitals. In a future pandemic or increase in community spread of COVID-19, hospitals need to be able to count on domestic manufacturers of surgical N95 respirators to deliver the equipment they need on a timely basis in order to protect health care workers and their patients. Sustaining a level of domestic production of National Institute for Occupational Safety and Health (NIOSH)-approved surgical N95 respirators would help to maintain that assurance. CMS recognizes that hospitals may incur additional costs when purchasing domestic NIOSH-approved surgical N95 respirators. Therefore, CMS is proposing payment adjustments under the IPPS and OPPS that would reflect, and offset, the additional marginal resource costs that hospitals face in procuring domestically made NIOSH-approved surgical N95 respirators. Under this proposal, these payments would be provided biweekly as interim lump-sum payments to the hospital and would be reconciled at cost report settlement. The rule also outlines the information that would be collected on the cost report to determine payments under this proposal, which would apply to cost reporting periods beginning on or after January 1, 2023.
Promoting Competition and Transparency Regarding the Effects of Provider Mergers, Acquisitions, Consolidations, and Changes in Ownership
President Biden’s Executive Order on Promoting Competition in the American Economy developed a whole-of-government effort to promote competition in the American economy. It also specifically identified that hospital consolidation has left many areas, especially rural communities, without good options for convenient and affordable health care services, and that hospitals in consolidated markets charge far higher prices. In response, this year CMS released data — for the first time — on hospital and skilled nursing facility mergers, acquisitions, consolidations, and changes in ownership going back to 2016, and will update the data quarterly going forward. The intent of this data release was to add transparency for the public and researchers to better understand the effect of mergers, acquisitions, consolidations, and changes in ownership on health care affordability in their communities. In this rule, CMS seeks comment on if there is additional data that should be released to further promote transparency and competition, and if there are additional provider types where information regarding mergers, acquisitions, consolidations, and changes in ownership should be released to the public.
Rural Sole Community Hospital Exemption to the Clinic Visit Payment Policy
CMS currently pays the Physician Fee Schedule (PFS)-equivalent payment rate for the clinic visit service when provided at an excepted off-campus provider-based department (PBD) paid under the OPPS, as a method to control the unnecessary increases in volume CMS had observed for that covered outpatient department service. The PFS-equivalent payment rate is approximately 40% of the OPPS payment rate, and the clinic visit is the most frequently billed service under the OPPS. In order to maintain access to care in rural areas, CMS is proposing to exempt Rural Sole Community Hospitals (SCHs) from this policy and pay for clinic visits furnished in excepted off-campus PBDs of these hospitals at the full OPPS rate. We believe that implementing this exemption would help to maintain access to care in rural areas by ensuring rural providers are paid for clinic visit services provided at off-campus PBDs at rates comparable to those paid by on-campus departments. This proposed exemption for rural SCHs is in keeping with prior CMS policies to provide rural SCHs a 7.1% add-on payment for OPPS services, to account for their higher costs compared to other hospitals, and to exempt rural SCHs from the 340B payment adjustment policy.
Supporting Organ Procurement and Research
CMS is supporting organ procurement and research in this proposed rule. CMS is proposing a method of accounting for research organs that will improve payment accuracy and lower the costs to procure and provide research organs to the research community. CMS is also proposing to address potential financial barriers to organ donation after cardiac death, which may increase organ procurement and promote equity within the transplant ecosystem.
In addition, CMS is requesting information to promote transparency and inform potential future organ acquisition payment policy. Specifically, CMS is requesting information on possible alternative methodologies for counting organs to calculate Medicare’s share of organ acquisition costs for transplant hospitals and organ procurement organizations.
OPPS Transitional Pass-through Payment for Drugs, Biologicals, and Devices
For CY 2023, CMS received eight applications for device pass-through payments. One of these applications (aprevo™ Intervertebral Fusion Device) received preliminary approval for pass-through payment status through our quarterly review process. CMS is soliciting public comment on all eight of these devices, and final determinations on whether the devices qualify (or continue to qualify) for transitional device pass-through status will be made in the CY 2023 OPPS/ASC final rule.
In addition, for CY 2023, CMS is proposing to resume our usual process of using claims data from two years prior to the year to set rates for the calendar year; specifically, CY 2021 claims data for CY 2023 OPPS rate setting. Therefore, CMS is not proposing to provide any additional quarters of separate payment for any device category whose pass-through payment status will expire between December 31, 2022 and September 30, 2023.
Finally, CMS is proposing to publicly post the completed OPPS device pass-through application forms and related materials that we receive from applicants online, excluding certain copyright or other materials that cannot otherwise be released to the public, beginning with applications received on or after January 1, 2023.
OPPS Payment for Software as a Service
Algorithm-driven services that assist practitioners in making clinical assessments can include clinical decision support software, clinical risk modeling, and computer aided detection (CAD). We refer to these technologies as software as a service (SaaS). For CY 2023, we are also seeking comments on the specific payment approach we might use for these services under the OPPS as SaaS-type technology becomes more widespread. We are also concerned about the potential for bias in algorithms and predictive modeling, and are seeking comments on how we could encourage software developers to prevent or mitigate the possibility of bias in new applications of this technology.
Partial Hospitalization Program
Partial Hospitalization Program (PHP) Rate Setting
The CY 2023 OPPS/ASC proposed rule would update Medicare payment rates for partial hospitalization program (PHP) services furnished in hospital outpatient departments and community mental health centers (CMHCs). The PHP is an intensive, structured outpatient program as an alternative to psychiatric hospitalization, consisting of a group of mental health services paid on a per diem basis under the OPPS, based on PHP per diem costs.
Update to PHP Per Diem Rates
CMS is proposing to maintain the existing rate structure, with a single PHP Ambulatory Payment Classification (APC) for each provider type, for days with three or more services per day. Consistent with OPPS, for this CY 2023 rate setting, CMS is proposing to use the CY 2021 claims data, but use the cost information from prior to the COVID-19 PHE; that is, the cost information that was available for the CY 2021 OPPS/ASC rulemaking. CMS believes this is appropriate and necessary for PHP services, based on our analysis indicating that the updated cost data are too influenced by the COVID-19 PHE for purposes of calculating the CY 2023 PHP payment rates.
Non-PHP Outpatient Behavioral Health Services Furnished Remotely to Partial Hospitalization Patients
CMS is clarifying that the proposal to pay under the OPPS for certain behavioral health therapy services furnished remotely, by hospital staff using communications technology to beneficiaries in their homes, would not be recognized as partial hospitalization services, but would be available to those in a partial hospitalization program. Specifically, CMS is clarifying that under the proposal, a hospital could bill for non-PHP outpatient services furnished to a PHP patient, including remote therapy services furnished by a hospital outpatient department. Hospitals would be permitted to bill for these remote non-PHP behavioral health services, but would need to continue to comply with documentation requirements that apply to PHP patients.
In addition, CMS is soliciting comments on the use of remote behavioral health services for PHP patients during the COVID-19 PHE. In addition, because CMHCs are only a provider of services for PHP by statute and, therefore, could not bill for remote services, we are soliciting comments on potential pathways to allow CMHCs to provide remote behavioral health services.
Hospital Outpatient/ASC/REH Quality Reporting Programs
CMS is proposing changes, as well as requesting comment, for the Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), and Rural Emergency Hospital Quality Reporting (REHQR) Programs to further meaningful measurement and reporting for quality of care in the outpatient setting.
Hospital Outpatient Quality Reporting (OQR) Program
The Hospital OQR Program is a pay-for-reporting quality program for the hospital outpatient department setting. The Hospital OQR Program requires hospitals to meet program requirements or receive a reduction of 2.0 percentage points in their annual payment update. In the CY 2023 OPPS/ASC proposed rule, CMS is proposing to update the Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery (OP-31) measure to be voluntary due to ongoing COVID-19 public health emergency (PHE). Interested parties have indicated that they are still recovering from the COVID-19 PHE, and that the requirement to report OP-31 would be burdensome due to national staffing and medical supply shortages, coupled with unprecedented changes in patient case volumes. CMS is also proposing to align Hospital OQR Program patient encounter quarters for chart-abstracted measures to the calendar year for annual payment update (APU) determinations, and add a targeting criterion in the selection of hospitals for data validation, for hospitals with fewer than four quarters of data subject to validation, due to receiving an extraordinary circumstance exception for one or more quarters.
CMS is also seeking comment on the future reimplementation of the Hospital Outpatient Volume on Selected Outpatient Surgical Procedures (OP–26) measure or the future adoption of another volume indicator as a quality measure.
Ambulatory Surgical Center Quality Reporting (ASCQR) Program
The ASCQR Program is a pay-for-reporting quality program for the ASC setting. The ASCQR Program requires ASCs to meet program requirements or receive a reduction of 2.0 percentage points in their annual fee schedule update.
In alignment with the proposal in the Hospital OQR Program, CMS is proposing to update the Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery (ASC-11) measure to be voluntary due to the ongoing COVID-19 public health emergency (PHE). Interested parties have indicated that they are still recovering from the COVID-19 PHE, and that the requirement to report ASC-11 would be burdensome due to national staffing and medical supply shortages, coupled with unprecedented changes in patient case volumes. CMS is also seeking comment on measures and topics for future considerations, including reimplementation of the ASC Volume on Selected ASC Surgical Procedures (ASC–7) measure or adoption of another volume indicator as a quality measure, a specialty center approach for ASC quality measures, and interoperability and EHR use in the ASCQR Program.
Rural Emergency Hospital Quality Reporting (REHQR) Program
Section 1861(kkk)(7) of the Social Security Act, as added by section 125(a)(1)(B) of Division CC of the CAA, requires the Secretary to establish quality measurement reporting requirements for Rural Emergency Hospitals (REHs).
CMS is seeking comment on several measures under consideration for the new Rural Emergency Hospital Quality Reporting Program, as well as on topics of interest for the REHQR Program for future rulemaking, including rural behavioral/mental health, rural maternal health, and rural telehealth services. CMS is also proposing that in order for REHs to participate in the REHQR Program, they must have an account with the Hospital Quality Reporting (HQR) secure portal and a designated Security Official.
Overarching Principles for Measuring Healthcare Quality Disparities Across CMS Quality Programs
Significant and persistent inequities in healthcare outcomes exist in the United States. Belonging to a racial or ethnic minority group; being a member of a religious minority; living with a disability; being a member of lesbian, gay, bisexual, transgender, and queer (LGBTQIA+) community; living in a rural or other underserved area; or being near or below the poverty level is often associated with worse health outcomes.
One approach under consideration for reducing inequity across our programs is the expansion of efforts to report quality measure results stratified by patient social risk factors and demographic variables. The Request for Information (RFI) included in the FY 2023 IPPS/LTCH PPS proposed rule (87 FR 28479), titled “Overarching Principles for Measuring Healthcare Quality Disparities Across CMS Quality Programs,” describes key considerations that we might take into account across all CMS quality programs, including the Hospital OQR, ASCQR, and REHQR Programs, when advancing the use of measure stratification to address healthcare disparities and advance health equity across our programs.
We ask that readers review the full RFI in the FY 2023 IPPS/LTCH PPS proposed rule for full details on these considerations. For comments and feedback on the application of these principles to the Hospital OQR Program Outpatient, ASC, and REH Quality Reporting Programs, readers can respond to this proposed rule.
Overall Hospital Quality Star Ratings
CMS and the nation’s hospitals work collaboratively to publicly report hospital quality performance information on the Care Compare website located at www.medicare.gov/care-compare/ and the Provider Data Catalog on data.cms.gov.
Care Compare displays hospital performance data in a consistent, unified manner to ensure the availability of credible information about the care delivered in the nation’s hospitals. The Overall Hospital Quality Star Rating was first introduced and reported on our Hospital Compare website in July 2016 (now reported on its successor website at https://www.medicare.gov/care-compare) and has been refreshed multiple times, with the most current refresh planned for 2022. The overarching goal of the Overall Hospital Quality Star Rating (Overall Star Rating) is to improve the usability and interpretability of information posted on Care Compare, a website designed for consumers to use along with their healthcare provider to make decisions on where to receive care. CMS developed this methodology with the input of a broad array of stakeholders to summarize the results of many measures currently publicly reported. The Overall Star Rating provides consumers with a simple overall rating generated by combining multiple dimensions of quality into a single summary score.
In this proposed rule, we are: (1) providing information on the previously finalized policy for inclusion of quality measure data from VHA hospitals; (2) proposing to amend the language of § 412.190(c) to propose that we would use publicly available measure results on Hospital Compare or its successor websites from a quarter within the prior twelve months (instead of the “prior year”); and (3) conveying that although CMS intends to publish Overall Hospital Quality Star Ratings in 2023, we may apply the suppression policy discussed in the CY 2021 OPPS/ASC proposed rule (85 FR 48996 through 49027) should data analysis demonstrate that the COVID-19 Public Health Emergency substantially affects the underlying measure data.
Protecting Our Programs’ Sustainability
CMS continues to prioritize reducing unnecessary increases in the volume of certain covered outpatient department (OPD) services through the use of a prior authorization process. In the CY 2023 OPPS/ASC proposed rule, CMS is proposing to require prior authorization for an additional service category: Facet Joint Injections and Nerve Destruction. This proposal would ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments without adding new documentation requirements for providers.