evekhm/cms_iom_500 huggingface dataset:
(iv)Differentiationin cost.In conducting surveys underclause (i), the Comptroller General shall determine and report toCongress if there is (and the extent of any) variation in hospitalacquisition costs for drugs among hospitals based on the volume ofcovered OPD services performed by such hospitals or other relevantcharacteristics of such hospitals (as defined by the Comptroller General).(v)Commenton proposed rates.Not later than 30days after the date the Secretary promulgated proposed rules settingforth the payment rates under subparagraph (A) for 2006, the ComptrollerGeneral shall evaluate such proposed rates and submit to Congressa report regarding the appropriateness of such rates based on thesurveys the Comptroller General has conducted under clause (i).(E)Adjustment in payment rates for overhead costs.(i)Medpacreport on drug apc design.The MedicarePayment Advisory Commission shall submit to the Secretary, not laterthan July 1, 2005, a report on adjustment of payment for ambulatorypayment classifications for specified covered outpatient drugs totake into account overhead and related expenses, such as pharmacyservices and handling costs. Such report shall include(I)a descriptionand analysis of the data available with regard to such expenses;(II)a recommendationas to whether such a payment adjustment should be made; and(III)ifsuch adjustment should be made, a recommendation regarding the methodologyfor making such an adjustment.(ii)Adjustmentauthorized.The Secretary may adjustthe weights for ambulatory payment classifications for specified coveredoutpatient drugs to take into account the recommendations containedin the report submitted under clause (i).(F)Classes of drugs.For purposes of thisparagraph:(i)Solesource drugs.The term sole sourcedrug means(I)a biologicalproduct (as defined under section 1861(t)(1)); or(II)a singlesource drug (as defined in section 1927(k)(7)(A)(iv)).(ii)Innovatormultiple source drugs.The term innovator multiple source drug has the meaning given suchterm in section 1927(k)(7)(A)(ii).(iii)
(ii)Innovatormultiple source drugs.The term innovator multiple source drug has the meaning given suchterm in section 1927(k)(7)(A)(ii).(iii)Noninnovator multiple source drugs.The term noninnovator multiple source drug has themeaning given such term in section 1927(k)(7)(A)(iii).(G)Reference average wholesale price.The term reference average wholesale price means,with respect to a specified covered outpatient drug, the average wholesaleprice for the drug as determined under section 1842(o) as of May 1, 2003.(H)Inapplicability of expenditures in determining conversion, weighting,and other adjustment factors.Additionalexpenditures resulting from this paragraph shall not be taken intoaccount in establishing the conversion, weighting, and other adjustmentfactors for 2004 and 2005 under paragraph (9), but shall be takeninto account for subsequent years.(15)Paymentfor new drugs and biologicals until hcpcs code assigned.With respect to payment under this part for an outpatient drugor biological that is covered under this part and is furnished aspart of covered OPD services for which a HCPCS code has not been assigned,the amount provided for payment for such drug or biological underthis part shall be equal to 95 percent of the average wholesale pricefor the drug or biological.(16)Miscellaneousprovisions.(A)Application of reclassification of certain hospitals.If a hospital is being treated as being located in a rural areaunder section 1886(d)(8)(E), that hospital shall be treated under this subsection as being locatedin that rural area.(B)Threshold for establishment of separate apcs for drugs.The Secretary shall reduce the threshold for the establishmentof separate ambulatory payment classification groups (APCs) with respectto drugs or biologicals to $50 per administration for drugs and biologicalsfurnished in 2005 and 2006.(C)
(C)Payment for devices of brachytherapy and therapeutic radiopharmaceuticalsat charges adjusted to cost.Notwithstandingthe preceding provisions of this subsection, for a device of brachytherapyconsisting of a seed or seeds (or radioactive source) furnished onor after January 1, 2004, and before July 1, 2008, and for therapeuticradiopharmaceuticals furnished on or after January 1, 2008, and beforeJuly 1, 2008, the payment basis for the device or therapeutic radiopharmaceuticalunder this subsection shall be equal to the hospitals chargesfor each deviceor therapeutic radiopharmaceutical furnished, adjustedto cost. Charges for such devices or therapeutic radiopharmaceuticalsshall not be included in determining any outlier payment under thissubsection.(D)[126]Special paymentrule.(i)Ingeneral.In the case of covered OPD servicesfurnished on or after April 1, 2013, in a hospital described in clause(ii), if(I)  the payment rate that would otherwiseapply under this subsection for stereotactic radiosurgery, completecourse of treatment of cranial lesion(s) consisting of 1 session thatis multisource Cobalt 60 based (identified as of January 1, 2013,by HCPCS code 77371 (and any succeeding code) and reimbursed as ofsuch date under APC 0127 (and any succeeding classification group));exceeds(II)  the payment rate that would otherwiseapply under this subsection for linear accelerator based stereotacticradiosurgery, complete course of therapy in one session (identifiedas of January 1, 2013, by HCPCS code G0173 (and any succeeding code)and reimbursed as of such date under APC 0067 (and any succeedingclassification group)),the payment rate for the servicedescribed in subclause (I) shall be reduced to an amount equal tothe payment rate for the service described in subclause (II).(ii)Hospital described.A hospital described in this clause is a hospital that is not(I)  located in a rural area (as definedin section 1886(d)(2)(D));(II)  classified as a rural referralcenter under section 1886(d)(5)(C); or
(I)  located in a rural area (as definedin section 1886(d)(2)(D));(II)  classified as a rural referralcenter under section 1886(d)(5)(C); or(III)  a sole community hospital (asdefined in section 1886(d)(5)(D)(iii)).(iii)Not budget neutral.In making any budget neutrality adjustments under this subsectionfor 2013 (with respect to covered OPD services furnished on or afterApril 1, 2013, and before January 1, 2014) or a subsequent year, theSecretary shall not take into account the reduced expenditures thatresult from the application of this subparagraph.(E)Application of appropriate use criteria for certain imaging services.For provisions relating to the application of appropriate usecriteria for certain imaging services, see section 1834(q).[127](17)QualityReporting.(A)Reduction in update for failure to report.(i)Ingeneral.For purposes of paragraph (3)(C)(iv)for 2009 and each subsequent year, in the case of a subsection (d)hospital (as defined in section 1886(d)(1)(B)) that does not submit,to the Secretary in accordance with this paragraph, data requiredto be submitted on measures selected under this paragraph with respectto such a year, the OPD fee schedule increase factor under paragraph(3)(C)(iv) for such year shall be reduced by 2.0 percentage points.(ii)Non-cumulativeapplication.A reduction under this subparagraphshall apply only with respect to the year involved and the Secretaryshall not take into account such reduction in computing the OPD feeschedule increase factor for a subsequent year.(B)Form and manner of submission.Eachsubsection (d) hospital shall submit data on measures selected underthis paragraph to the Secretary in a form and manner, and at a time,specified by the Secretary for purposes of this paragraph.(C)Development of outpatient measures.(i)
(C)Development of outpatient measures.(i)Ingeneral.The Secretary shall developmeasures that the Secretary determines to be appropriate for the measurementof the quality of care (including medication errors) furnished byhospitals in outpatient settings and that reflect consensus amongaffected parties and, to the extent feasible and practicable, shallinclude measures set forth by one or more national consensus buildingentities.(ii)Construction.Nothing in this paragraph shall be construed as preventing theSecretary from selecting measures that are the same as (or a subsetof) the measures for which data are required to be submitted undersection 1886(b)(3)(B)(viii).(D)Replacement of measures.For purposesof this paragraph, the Secretary may replace any measures or indicatorsin appropriate cases, such as where all hospitals are effectivelyin compliance or the measures or indicators have been subsequentlyshown not to represent the best clinical practice.(E)Availability of data.The Secretaryshall establish procedures for making data submitted under this paragraphavailable to the public. Such procedures shall ensure that a hospitalhas the opportunity to review the data that are to be made publicwith respect to the hospital prior to such data being made public.The Secretary shall report quality measures of process, structure,outcome, patients perspectives on care, efficiency, and costsof care that relate to services furnished in outpatient settings inhospitals on the Internet website of the Centers for Medicare andMedicaid Services.(18)[128]Authorization of adjustment forcancer hospitals.(A)Study.The Secretary shall conducta study to determine if, under the system under this subsection, costsincurred by hospitals described in section 1886(d)(1)(B)(v) with respectto ambulatory payment classification groups exceed those costs incurredby other hospitals furnishing services under this subsection (as determinedappropriate by the Secretary). In conducting the study under thissubparagraph, the Secretary shall take into consideration the costof drugs and biologicals incurred by such hospitals.(B)
(B)Authorization of adjustment.Insofaras the Secretary determines under subparagraph (A) that costs incurredby hospitals described in section 1886(d)(1)(B)(v) exceed those costs incurred by other hospitalsfurnishing services under this subsection, the Secretary shall, subjectto subparagraph (C), provide for an appropriate adjustment under paragraph(2)(E) to reflect those higher costs effective for services furnishedon or after January 1, 2011.(C)Target pcr adjustmentIn applying section 419.43(i) of title 42 of the Code of FederalRegulations to implement the appropriate adjustment under this paragraphfor services furnished on or after January 1, 2018, the Secretaryshall use a target PCR that is 1.0 percentage points less than thetarget PCR that would otherwise apply. In addition to the percentagepoint reduction under the previous sentence, the Secretary may considermaking an additional percentage point reduction to such target PCRthat takes into account payment rates for applicable items and servicesdescribed in paragraph (21)(C) other than for services furnished byhospitals described in section 1886(d)(1)(B)(v). In making any budget neutrality adjustmentsunder this subsection for 2018 or a subsequent year, the Secretaryshall not take into account the reduced expenditures that result fromthe application of this subparagraph.(19)Flooron area wage adjustment factor for hospital outpatient departmentservices in frontier states.(A)In general.Subject to subparagraph(B), with respect to covered OPD services furnished on or after January1, 2011, the area wage adjustment factor applicable under the paymentsystem established under this subsection to any hospital outpatientdepartment which is located in a frontier State (as defined in section 1886(d)(3)(E)(iii)(II)) maynot be less than 1.00. The preceding sentence shall not be appliedin a budget neutral manner.(B)Limitation.This paragraph shall notapply to any hospital outpatient department located in a State thatreceives a non-labor related share adjustment under section 1886(d)(5)(H).(20)
(B)Limitation.This paragraph shall notapply to any hospital outpatient department located in a State thatreceives a non-labor related share adjustment under section 1886(d)(5)(H).(20)Notbudget neutral application of reduced expenditures resulting fromquality incentives for computed tomography.The Secretary shall not take into account the reduced expendituresthat result from the application of section 1834(p) in making anybudget neutrality adjustments this subsection.[129](21)Servicesfurnished by an off-campus outpatient department of a provider[130].(A)Applicable items and services.Forpurposes of paragraph (1)(B)(v) and this paragraph, the term applicable items and services means items and services otherthan items and services furnished by a dedicated emergency department(as defined in section 489.24(b) of title 42 of the Code of FederalRegulations).(B)Off-campus outpatient department of a provider.(i)Ingeneral.[131]For purposes ofparagraph (1)(B)(v) and this paragraph, subject to the subsequentprovisions of this subparagraph, the term off- campus outpatientdepartment of a provider means a department of a provider(as defined in section 413.65(a)(2) of title 42 of the Code of FederalRegulations, as in effect as of the date of the enactment of thisparagraph) that is not located(I)on the campus(as defined in such section 413.65(a)(2)) of such provider; or(II)withinthe distance (described in such definition of campus) from a remotelocation of a hospital facility (as defined in such section 413.65(a)(2)).(ii)Exception.For purposes of paragraph (1)(B)(v) and this paragraph, theterm off-campus outpatient department of a provider shall not include a department of a provider (as so defined) thatwas billing under this subsection with respect to covered OPD servicesfurnished prior to the date of the enactment of this paragraph.(iii)
(iii)Deemed treatment for 2017.For purposesof applying clause (ii) with respect to applicable items and servicesfurnished during 2017, a department of a provider (as so defined)not described in such clause is deemed to be billing under this subsectionwith respect to covered OPD services furnished prior to November 2,2015, if the Secretary received from the provider prior to December2, 2015, an attestation (pursuant to section 413.65(b)(3) of title42 of the Code of Federal Regulations) that such department was adepartment of a provider (as so defined).(iv)Alternativeexception beginning with 2018.For purposesof paragraph (1)(B)(v) and this paragraph with respect to applicableitems and services furnished during 2018 or a subsequent year, theterm off-campus outpatient department of a provider also shall not include a department of a provider (as so defined)that is not described in clause (ii) if(I) the Secretary receives from the provideran attestation (pursuant to such section 413.65(b)(3)) not later thanDecember 31, 2016 (or, if later, 60 days after the date of the enactmentof this clause), that such department met the requirements of a departmentof a provider specified in section 413.65 of title 42 of the Codeof Federal Regulations;(II) the provider includes such departmentas part of the provider on its enrollment form in accordance withthe enrollment process under section 1866(j); and(III) the department met the mid-buildrequirement of clause (v) and the Secretary receives, not later than60 days after the date of the enactment of this clause, from the chiefexecutive officer or chief operating officer of the provider a writtencertification that the department met such requirement.(v)Mid-buildrequirement described.The mid-buildrequirement of this clause is, with respect to a department of a provider,that before November 2, 2015, the provider had a binding written agreementwith an outside unrelated party for the actual construction of suchdepartment.
(vi)Exclusion for certain cancerhospitals.[132]For purposes of paragraph(1)(B)(v) and this paragraph with respect to applicable items andservices furnished during 2017 or a subsequent year, the term off-campus outpatient department of a provider also shallnot include a department of a provider (as so defined) that is notdescribed in clause (ii) if the provider is a hospital described insection 1886(d)(1)(B)(v) and(I) in the case of a department thatmet the requirements of section 413.65 of title 42 of the Code ofFederal Regulations after November 1, 2015, and before the date ofthe enactment of this clause, the Secretary receives from the provideran attestation that such department met such requirements not laterthan 60 days after such date of enactment; or(II) in the case of a department thatmeets such requirements after such date of enactment, the Secretaryreceives from the provider an attestation that such department meetssuch requirements not later than 60 days after the date such requirementsare first met with respect to such department.(vii)Audit.[133]Not later than December 31, 2018, the Secretary shall auditthe compliance with requirements of clause (iv) with respect to eachdepartment of a provider to which such clause applies. Not later than2 years after the date the Secretary receives an attestation underclause (vi) relating to compliance of a department of a provider withrequirements referred to in such clause, the Secretary shall auditthe compliance with such requirements with respect to the department.and If the Secretary finds as a result of an audit under this clausethat the applicable requirements were not met with respect to suchdepartment, the department shall not be excluded from the term off- campus outpatient department of a provider under suchclause.(viii)Implementation.For purposes of implementingclauses (iii) through (vii):(I) Notwithstanding any other provisionof law, the Secretary may implement such clauses by program instructionor otherwise.(II) Subchapter I of chapter 35 of title44, United States Code, shall not apply.
(I) Notwithstanding any other provisionof law, the Secretary may implement such clauses by program instructionor otherwise.(II) Subchapter I of chapter 35 of title44, United States Code, shall not apply.(III)[134]For purposes of carrying out this subparagraph with respectto clauses (iii) and (iv) (and clause (vii) insofar as it relatesto clause (iv)), $10,000,000 shall be available from the Federal SupplementaryMedical Insurance Trust Fund under section 1841, to remain availableuntil December 31, 2018. For purposes of carrying out this subparagraphwith respect to clause (vi) (and clause (vii) insofar as it relatesto such clause), $2,000,000 shall be available from the Federal SupplementaryMedical Insurance Trust Fund under section 1841, to remain availableuntil expended.(C)Availability of payment under other payment systems.Payments for applicable items and services furnished by an off-campusoutpatient department of a provider that are described in paragraph(1)(B)(v) shall be made under the applicable payment system underthis part (other than under this subsection) if the requirements forsuch payment are otherwise met.(D)Information needed for implementation.Each hospital shall provide to the Secretary such information asthe Secretary determines appropriate to implement this paragraph andparagraph (1)(B)(v) (which may include reporting of information ona hospital claim using a code or modifier and reporting informationabout off-campus outpatient departments of a provider on the enrollmentform described in section 1866(j)).(E)Limitations.There shall be no administrativeor judicial review under section 1869, section 1878, or otherwiseof the following:(i)The determinationof the applicable items and services under subparagraph (A) and applicablepayment systems under subparagraph (C).(ii)The determinationof whether a department of a provider meets the term described insubparagraph (B).(iii)Any informationthat hospitals are required to report pursuant to subparagraph (D).(iv)The determinationof an audit under subparagraph (B)(vii).[135]
(22)[136]Review and revisions of paymentsfor non-opioid alternative treatments.(A)In general.With respect to paymentsmade under this subsection for covered OPD services (or groups ofservices), including covered OPD services assigned to a comprehensiveambulatory payment classification, the Secretary(i)shall, as soonas practicable, conduct a review (part of which may include a requestfor information) of payments for opioids and evidence-based non-opioidalternatives for pain management (including drugs and devices, nerveblocks, surgical injections, and neuromodulation) with a goal of ensuringthat there are not financial incentives to use opioids instead ofnon-opioid alternatives;(ii)may, as theSecretary determines appropriate, conduct subsequent reviews of suchpayments; and(iii)shall considerthe extent to which revisions under this subsection to such payments(such as the creation of additional groups of covered OPD servicesto classify separately those procedures that utilize opioids and non-opioidalternatives for pain management) would reduce payment incentivesto use opioids instead of non-opioid alternatives for pain management.(B)Priority.In conducting the review underclause (i) of subparagraph (A) and considering revisions under clause(iii) of such subparagraph, the Secretary shall focus on covered OPDservices (or groups of services) assigned to a comprehensive ambulatorypayment classification, ambulatory payment classifications that primarilyinclude surgical services, and other services determined by the Secretarywhich generally involve treatment for pain management.(C)Revisions.If the Secretary identifiesrevisions to payments pursuant to subparagraph (A)(iii), the Secretaryshall, as determined appropriate, begin making such revisions forservices furnished on or after January 1, 2020. Revisions under theprevious sentence shall be treated as adjustments for purposes ofapplication of paragraph (9)(B).(D)Rules of construction.Nothing in thisparagraph shall be construed to preclude the Secretary(i)from conductinga demonstration before making the revisions described in subparagraph(C); or(ii)prior to implementationof this paragraph, from changing payments under this subsection forcovered OPD services (or groups of services) which include opioidsor non-opioid alternatives for pain management.
(ii)prior to implementationof this paragraph, from changing payments under this subsection forcovered OPD services (or groups of services) which include opioidsor non-opioid alternatives for pain management.(u)IncentivePayments for Physician Scarcity Areas.(1)In general.In the case of physicians services furnished on or afterJanuary 1, 2005, and before July 1, 2008(A)by a primarycare physician in a primary care scarcity county (identified underparagraph (4)); or(B)by a physicianwho is not a primary care physician in a specialist care scarcitycounty (as so identified),in addition to the amount of payment that would otherwise bemade for such services under this part, there also shall be paid anamount equal to 5 percent of the payment amount for the service underthis part.(2)Determinationof ratios of physicians to medicare beneficiaries in area.Based upon available data, the Secretary shall establish foreach county or equivalent area in the United States, the following:(A)Number of physicians practicing in the area.The number of physicians who furnish physicians servicesin the active practice of medicine or osteopathy in that county orarea, other than physicians whose practice is exclusively for theFederal Government, physicians who are retired, or physicians whoonly provide administrative services. Of such number, the number ofsuch physicians who are(i)primary carephysicians; or(ii)physicianswho are not primary care physicians.(B)Number of medicare beneficiaries residing in the area.The number of individuals who are residing in the county andare entitled to benefits under part A or enrolled under this part,or both (in this subsection referred to as individuals).(C)Determination of ratios.(i)Primarycare ratio.The ratio (in this paragraphreferred to as the primary care ratio) of the numberof primary care physicians (determined under subparagraph (A)(i)),to the number of individuals determined under subparagraph (B).(ii)Specialistcare ratio.The ratio (in this paragraphreferred to as the specialist care ratio) of the numberof other physicians (determined under subparagraph (A)(ii)), to thenumber of individuals determined under subparagraph (B).(3)