evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The specific services to which this policy applies can be identified by OPPS status indicator.  CMS will identify the status indicators of the HCPCS codes to which the reduction applies each year in the change request that announces changes to the OPPS for the forthcoming calendar year.  Also, the status indicators for the services (identified by HCPCS codes) to which the reduction applies can be found in the OPPS final rule for the year of interest under Hospital Outpatient Regulations and Notices at www.cms.hhs.gov/HospitalOutpatientPPS/.  The services excluded from the payment reduction may change each year if the method of calculating payment under the OPPS changes.   10.6.2.3 - Contractor Re sponsibilities  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)   CMS claims processing software will automatically reduce payment to Subsection (d) hospitals when those hospitals that fail to meet the quality reporting require ments bill for services to which the reduced update applies.  However, contractors must update the Outpatient Provider Specific File (OPSF) quality reporting field when CMS furnishes the list of hospitals to which the payment reduction applies.  The FISS auto-populates the Hospital Quality Indicator field of the OPSF field with a 1 for all hospitals.  Once CMS has issued the list of hospitals failing to meet the requirements, Medicare contractors must remove the 1 in the Hospital Quality Indicator field  for each Subsection (d) hospital that fails to meet the quality reporting requirements.  Contractors make no changes to the 1 indicator for hospitals that are not Subsection (d) hospitals providing OPPS services or for hospitals that are Subsection (d) hospitals providing OPPS services that are not listed as failing the requirements.
(Medicare Claims Processing Manual)
CMS sends Medicare contractors the file of hospitals to which the reduction applies for a given calendar year by a Joint Signature Memorandum/Technical Direction Letter as soon as the list is available.  This will be sent as soon as possible, expected to be on or about December 1 of each year preceding the calendar year to which the payment reduction applies.  Should a Subsection (d) hospital later be determined to have met the criteria after dissemination of this list, CMS will change the hospitals status.  CMS will notify Medicare contractors of the change in status and contractors must update the OPSF as needed and must mass adjust paid claims.   For new hospitals, Medicare contractors must provide information to the Quality Contractor to be specified by CMS as soon as possible so that the Quality Contractor can enter the provider information into the Program Resource System and follow through with ensuring provider participation with the requirements for quality data reporting, if applicable.  CMS will notify Medicare contractors of how to contact the Quality Contractor each year in the annual OPPS update change request.  This allows the Quality Contractor the opportunity t o contact new facilities as early as possible in the calendar year to inform them of the hospital outpatient quality reporting requirements.  As soon as possible, Medicare contractors must provide the following information on newly participating hospitals to the Quality Contractor to be specified by CMS:   State code;   Provider name;  Provider ID numbe;   Medicare accept dat;e   Contact name (if available); and   Telephone number.  10.6.2.4 - Application of the Payment Reduction Factor in Calculation of the Reduced Payment and Reduced Copayment  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)
(Medicare Claims Processing Manual)
For services to which the payment adjustment applies, CMS calculates a payment reduction factor that is used in the OPPS Pricer  to adjust the payments for hospitals that fail to meet the reporting requirements.  CMS calculates this factor by dividing the OPPS conversion factor that incorporates the reduced update factor by the OPPS conversion factor that incorporates the full upda te factor for the applicable calendar year.   This ratio is applied to the full national unadjusted payment amount for a service subject to the payment reduction in order to calculate the reduced payment amount.  Similarly, this ratio is applied to the full national unadjusted copayment for an applicable service to calculate the reduced copayment that may be collected from the beneficiary by the hospital.  The payment reduction factor will be included in the annual OPPS update change request and may also be found in the applicable OPPS final rule, which can be found at www.cms.hhs.gov/HospitalOutpatientPPS/ under Hospital Outpatient Regulations and Notices.   10.6.3 - Payment Adjustment for Certain Cancer Hospitals  (Rev. 2453, Issued: 04- 26-12, Effective: 01-01-12, Implementation: 05-29 -12)
(Medicare Claims Processing Manual)
10.6.3 - Payment Adjustment for Certain Cancer Hospitals  (Rev. 2453, Issued: 04- 26-12, Effective: 01-01-12, Implementation: 05-29 -12)  Section 3138 of the Affordable Care Act requires CMS to conduct a study to determine if, under the OPPS, outpatient costs incurred by 11 specified cancer hospitals exceed the costs incurred by other hospitals furnishing services under the OPPS.  In addition, Section 3138 of the Affordable Care Act provides that if the specified cancer hospitals costs are determined to be greater  than the costs of other hospitals furnishing services under the OPPS, CMS shall provide a payment adjustment to the 11 specified cancer hospitals that will appropriately reflect these higher outpatient costs.  We determined that outpatient costs incurred by the 11 specified cancer hospitals were greater than the costs incurred by other OPPS hospitals.  Therefore, consistent with Section 3138 of the Affordable Care Act, we adopted a policy to provide additional payments to each of the 11 cancer hospitals so that each cancer hospitals final payment to cost ratio (PCR) for services provided in a given calendar year is equal to the weighted average PCR (which we refer to as the target PCR) for other hospitals paid under the OPPS.  The target PCR is set in advance of the calendar year and is calculated using the most recent submitted or settled cost report data that are available at the time of final rulemaking for the calendar year.   The cancer hospital payment adjustment will be made through interim monthly payments with the final payment adjustment amount calculated based on the providers settled cost report.  The calculation for the monthly cancer hospital payment adjustment amount is described as follows:    Step 1 - Compute the cancer hospital target pay ment amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and adjust the total charges to cost by multiplying them by the outpatient cost- to-charge ratio and then multiplying this amount by the target PCR for the calendar year.
(Medicare Claims Processing Manual)
Step 2 - Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all APCs, as well as all outlier payments (including reconciled outlier payments and the time value of money) and transitional pass -through payments for drugs, biological and/or devices for those same claims paid during the month as those used in Step 1.   If the result is greater than the result of Step 1, go to Step 4.  No additional payment is due this month.  Step 3 - Subtract the result of Step 2 from the result of Step 1 and pay .85 times this amount.     Step 4 -  When the result of step 2 is greater than the result of Step 1 for the final month of a providers cost report period, do nothing more.  When the result of Step 2 is greater than the result of Step 1 for any other month, store all Step 1 and Step 2 totals and include these totals with the totals for the next months additional payment calculation.   10.6.3.1 - Payment Adjustment for C ertain Cancer Hospitals for CY 2012 and CY 2013  (Rev. 2611, Issued: 12- 14-12, Effective: 01- 01-13, Implementation, 01- 07-13)  The target PCR that should be used in the calculation of the interim monthly payments associated with the cancer hospital adjustme nt, as described above in section 10.6.3, and at final cost report settlement is 0.91 for hospital outpatient services furnished on or after January 1, 2012 through December 31, 2013.   10.6.3.2 - Payment Adjustment for Certain Cancer Hospitals for CY 2014 (Rev. 2845, Issued: 12- 27-13, Effective: 01- 01-14, Implementation: 01- 06-14)  The target PCR that should be used in the calculation of the interim monthly payments associated with the cancer hospital adjustment, as described above in section 10.6.3, and at  final cost report settlement is 0.89 for hospital outpatient services furnished on or after January 1, 2014 through December 31, 2014.   10.6.3.3 - Payment Adjustment for Certain Cancer Hospitals Beginning CY 2015 (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)
(Medicare Claims Processing Manual)
10.6.3.3 - Payment Adjustment for Certain Cancer Hospitals Beginning CY 2015 (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  The target PCR that should be used in the calculation of the interim monthly payments associated with the cancer hospital adjustment, as described above in section 10.6.3, and at final cost report settlement is 0.90 for hospital outpatient services furnished on or after January 1, 2015 through December 31, 2015.   10.6.3.4 - Payment Adjustment for Certain Cancer Hospitals Beginning CY 2016 (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  The target PCR that should be used in the calculation of the interim monthly payments associated with the cancer hospital adjustment, as described above in section 10.6.3, and at final cost report settlement is 0.92 for hospital outpatient services furnished on or after January 1, 2016 through December 31, 2016.   10.6.3.5 - Payment Adjustment for Certain Cancer Hospitals Beginning CY 2017 (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  The target PCR that should be used in the calculation of the interim monthly payments associated with the cancer hospital adjustment, as described above in section 10.6.3, and at final cost report settlement is 0.91 for hospital outpatient services furnished on or after January 1, 2017 through Dec ember 31, 2017.   10.6.3.6 - Payment Adjustment for Certain Cancer Hospitals Beginning CY 2018 (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)
(Medicare Claims Processing Manual)
10.6.3.6 - Payment Adjustment for Certain Cancer Hospitals Beginning CY 2018 (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  Section 16002(b) of the 21st Century Cures Act requires that, for CY 2018 and subse quent calendar years, the target PCR that should be used in the calculation of the interim monthly payments associated with the cancer hospital adjustment, as described above in section 10.6.3, and at final cost report settlement is  reduced by 0.01. After including this reduction, for hospital outpatient services furnished on or after January 1, 2018 through December 31, 2018, the target PCR is 0.88. 10.6.3.7 - Payment Adjustment for Certain Cancer Hospitals Beginning CY 2019                                                                                                       (Rev.  4513, Issued: 02- 04-2020, Effective: 01-01- 2020, Implementation: 01-06-2020)  Section 16002(b) of the 21st Century Cures Act requires that, for CY 2018 and subsequent calendar ye ars, the target PCR that should be used in the calculation of the interim monthly payments associated with the cancer hospital adjustment, as described above in section 10.6.3, and at final cost report settlement is reduced by 0.01. After including this reduction, for hospital outpatient services furnished on or after January 1, 2019 through December 31, 2019, the target PCR is 0.88.  10.6.3.8 - Payment Adjustment for Certain Cancer Hospitals Beginning CY 2020                                                                                                      (Rev. 4513, Issued: 02-04-2020, Effective: 01-01- 2020, Implementation: 01-06-2020)  Section 16002(b) of the 21st Century Cures Act requires that, for CY 2018 and subsequent calendar years, the target PCR that should be used in the calculation of the interim monthly payments associated with the cancer hospital adjustment, as described above in section 10.6.3, and at final cost report settlement is reduced by 0.01. After including this reduction, for hospital outpatient services furnished on or after January 1, 2020 through December 31, 2020, the target PCR is 0.89.  10.7 - Outliers  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)
(Medicare Claims Processing Manual)
10.7 - Outliers  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)     10.7.1 - Outlier Adjustments  (Rev. 3685, Issued: 12- 22-16, Effective: 01-01-17, Implementation: 01-03-17)  The OPPS incorporates an outlier adjustment to ensure that outpatient servi ces with variable and potentially significant costs do not pose excessive financial risk to providers.  Section 419.43(f) of the Code of Federal Regulations excludes drugs, biologicals and items and services paid at charges adjusted to cost from outlier payments.  The OPPS determines eligibility for outliers using either a multiple threshold, which is the product of a multiplier and the APC payment rate, or a combination of a multiple and fixed-dollar threshold.  A service or group of services becomes eli gible for outlier payments when the cost of the service or group of services estimated using the hospitals most recent overall cost- to-charge ratio (CCR) separately exceeds each relevant threshold.  For community mental health centers (CMHCs), CMS determines whether billed partial hospitalization services are eligible for outlier payments using a multiple threshold specific to CMHCs.  The outlier payment is a percentage of the difference between the cost estimate and the multiple threshold.  The CMS OPPS W eb site at www.cms.hhs.gov/HospitalOutpatientPPS/ under Annual Policy Files includes a table depicting the specific hospital and CMHC outlier thresholds and the payment percentages in place for each year of the OPPS.   Beginning in CY 2000, CMS determined outlier payments on a claim basis.  CMS determined a claims eligibility to receive outlier payments using a multiple threshold.  A claim was eligible for outlier payments when the total estima te of charges reduced to cost for the entire claim exceeded a multiple of the total claim APC payment amount.  As provided in Section 1833(t)(5)(D), CMS used each hospitals overall CCR rather than a CCR for each department within the hospital.  CMS continues to use an overall hospital CCR specific to ancillary cost centers to estimate costs from charges for outlier payments.
(Medicare Claims Processing Manual)
In CY 2002, CMS adopted a policy of calculating outlier payments based on each individual OPPS (line- item) service.  CMS continued using a multiple threshold, modified to be a multiple of each services APC payment rather than the total claim APC payment amount, and an overall hospital CCR to estimate costs from charges.  For CY 2004, CMS established separate  multiple  outlier thresholds for hospitals and CMHCs.   Beginning in CY 2005, for hospitals only, CMS implemented the use of a fixed- dollar threshold to better target outlier payments to complex and costly services that pose hospitals with significant financial risk.  The current hospital outlier policy is calculated on a service basis using both fixed- dollar and multiple thresholds to determine outlier eligibility.   The current outlier payment is determined by:    Calculating the cost related to an OPPS line -item service, including a pro rata portion of the total cost of packaged services on the claim and adding payment for any device with pass - through status to payment for the associated procedure, by multiplying the total charges for OPPS services by each hospitals overall CCR (see 10.11.8 of this chapter); and    Determining whether the total cost for a service exceeds 1.75 times the OPPS payment and separately exceeds the fixed -dollar threshold determined each year; and    If total cost for the service exceeds both thresholds, the  outlier payment is 50 percent of the amount by which the cost exceeds 1.75 times the OPPS payment.  The total cost of all packaged items and services, including the cost of uncoded revenue code lines with a revenue code status indicator of N, that appea r on a claim is allocated across all separately paid OPPS services that appear on the same claim.  The proportional amount of total packaged cost allocated to each separately paid OPPS service is based on the percent of the APC payment rate for that servic e out of the total APC payment for all separately paid OPPS services on the claim.
(Medicare Claims Processing Manual)
To illustrate, assume the total cost of all packaged services and revenue codes on the claim is $100, and the three APC payment amounts paid for OPPS services on the claim are $200, $300, and $500 (total APC payments of $1000).  The first OPPS service or line -item is allocated $20 or 20 percent of the total cost of packaged services, because the APC payment for that service/line- item represents 20 percent ($200/$1000) of tot al APC payments on the claim.  The second OPPS service is allocated $30 or 30 percent of the total cost of packaged services, and the third OPPS service is allocated $50 or 50 percent of the total  cost of packaged services.   If a claim has more than one su rgical  service line  with a status indicator (SI) of S or T and any lines with an SI of S or T have less than $1.01 as charges, charges for all S and/or T lines are summed and the charges are then divided across S and/or T  lines in proportion to their APC payment rate. The new charge amount is used in place of the submitted charge amount in the line -item outlier calculation.   If a claim includes a composite payment that pays for more than one otherwise separately paid servi ce, the charges for all services included in the composite are summed up to one line. To determine outlier payments, CMS estimates a single cost for the composite APC from the summarized charges.  Total packaged cost is allocated to the composite line -item in proportion to other separately paid services on the claim.   In accordance with Section 1833(t)(5)(A)(i) of the Act, if a claim includes a device receiving pass -through payment, the payment for the pass -through device is added to the payment for the ass ociated procedure, less any offset, in determining the associated procedures eligibility for outlier payment, and the outlier payment amount.  The estimated cost of the device, which is equal to payment, also is added to the estimated cost of the procedur e to ensure that cost and payment both contain the procedure and device costs when determining the procedures eligibility for an outlier payment.    CMHC Outlier Payment Cap
(Medicare Claims Processing Manual)
Beginning for services provided on or after January 1, 2017, outlier payments made  to CMHCs are subject to a cap, applied at the individual CMHC level, so that each CMHCs total outlier payments for the calendar year do not exceed 8 percent of that CMHCs total per diem payments for the calendar year.  Total per diem payments are total Medicare per diem payments plus the total beneficiary share of those per diem payments.   Future updates will be issued in a Recurring Update Notification.   10.7.2 - Outlier Reconciliation  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  10.7.2.1 - Identifying Hospitals and CMHCs Subject to Outlier Reconciliation  (Rev.  2111, Issued: 12- 03-10, Effective: 04- 01-11, Implementation: 04- 04-11)  A. General   Under 419.43(d)(6)(i), for hospital outpatient services furnished during cost  reporting periods beginning on or after January 1, 2009, OPPS high cost outlier payments may be reconciled upon cost report settlement to account for differences between the overall ancillary CCR used to pay the claim at its original submission by the provider, and the CCR determined at final settlement of the cost reporting period during which the service was furnished.  Hospitals and CMHCs that Medicare contractors identify using the criteria listed below are subject to the OPPS outlier reconciliation policies described in this section.  OPPS outlier payments are reconciled if the CMS Central Office and Regional Office confirm that reconciliation is appropriate.  Services with an APC payment paid at charges adjusted to cost are not subject to reconciliati on policies.   Subject to the approval of the CMS Central Office and Regional Office, a hospitals outpatient outlier claims are reconciled at the time of cost report final settlement if they meet the following criteria:   1. The actual overall ancillary CCR  is found to be plus or minus 10 percentage points or more from the CCR used during that time period to make OPPS outlier payments, and    2. Total OPPS outlier payments in that cost reporting period exceed $500,000.
(Medicare Claims Processing Manual)
2. Total OPPS outlier payments in that cost reporting period exceed $500,000.   Subject to the approval of the CMS Central Office and Regional Office, a CMHCs outlier claims are reconciled at the time of cost report final settlement if they meet the following criteria:   1. The actual overall CCR is found to be plus or minus 10 percentage points or more from the CCR used during that time period to make OPPS outlier payments, and   2. Any CMHC OPPS outlier payments are made in that cost reporting period.  To determine if a hospital or CMHC meets the criteria above, the Medicare contractor shall incorporate all the adjustment s from the cost report, run the cost report, calculate the revised CCR, and compute the actual overall ancillary CCR prior to issuing a Notice of Program Reimbursement (NPR).  If the criteria for OPPS outlier reconciliation are not met, the cost report sha ll be finalized.  If the criteria for reconciliation are met, Medicare contractors shall follow the instructions below in 10.7.2.4 of this chapter.  The NPR cannot be issued nor can the cost report be finalized until OPPS outlier reconciliation is complet e.  These hospital and CMHC cost reports will remain open until their claims have been processed for OPPS outlier reconciliation.  As stated above, if a cost report is reopened after final settlement and as a result of this reopening there is a change to t he CCR (which could trigger or affect OPPS outlier reconciliation and outlier payments),  Medicare contractors shall notify the CMS Central and Regional Offices for further instructions.  Notification to the CMS Central Office shall be sent to the address a nd email address provided in 10.11.3.1.  Any cost report that has been final settled that meets the qualifications for OPPS outlier reconciliation shall be reopened. Medicare contractors shall notify the CMS Central Office and Regional Office that the OPP S outlier payments need to be reconciled, using the procedures included in 10.7.2.4.  After CMS approval of the reconciliation, the Medicare contractor shall issue a reporting notice to the provider.  B. Hospitals and CMHCs Already Flagged for Outlier Re conciliation   Medicare contractors shall have until April 25, 2011 to submit via email to outliersopps@cms.hhs.gov