Ohio Administrative Code › Title 4123 - Bureau of Workers' Compensation › Chapter 4123-6 - Health Partnership Program › Section 4123-6-37.2 - Payment of hospital outpatient services

Current through all regulations passed and filed through July 1, 2024
(A)
			 HPP:
Unless an MCO has negotiated a different payment rate with a
				hospital pursuant to rule
				4123-6-10 of the Administrative
				Code, reimbursement for hospital outpatient services with a date of service of
				May 1, 2024 or after will be the applicable rate set forth in
				this rule as follows:
(1) Except as
			 otherwise provided in this rule, reimbursement for hospital outpatient services
			 will be equal to the applicable medicare reimbursement rate for the hospital
			 outpatient service under the medicare outpatient prospective payment system as
			 implemented by the materials specified in paragraph (A)(10) of this rule,
			 multiplied by a bureau-specific payment adjustment factor, which will be
			 2.758
			 for children's hospitals and 1.485 for all hospitals other than children's
			 hospitals, plus the add-on payments set forth in paragraph (A)(4) of this rule,
			 if applicable.
BWC will use the medicare integrated outpatient code editor and
				medicare medically unlikely edits in effect as implemented by the materials
				specified in paragraph (A)(9) of this rule and table 8 of the appendix to this
				rule to process bills for hospital outpatient services under this rule;
				however, BWC will not apply the outpatient code edits identified in table 1 of
				the appendix to this rule.
BWC will not apply the annual medicare outpatient prospective
				payment system outlier, hold harmless, and exempt cancer hospital
				reconciliation processes to payments for hospital outpatient services under
				this rule.
For purposes of this rule, hospitals are identified as critical
				access hospitals, rural sole community hospitals, essential access community
				hospitals and exempt cancer hospitals based on the hospitals' designation in
				the medicare outpatient provider specific file in effect implemented by the
				materials specified in paragraph (A)(10) of this rule.
For purposes of this rule, the following hospitals are
				recognized as "children's hospitals": nationwide children's hospital
				(Columbus), Cincinnati children's hospital medical center, shriners hospital
				for children (Cincinnati), university hospitals rainbow babies and children's
				hospital (Cleveland), Toledo children's hospital, children's hospital medical
				center of Akron, and children's medical center of Dayton.
Reimbursement for any hospital outpatient services identified
				in table 6 of the appendix to this rule will be determined using the medicare
				outpatient prospective payment system methodology as set forth in this
				paragraph, applying the status indicator and ambulatory payment classification
				specified for the service in table 6 of the appendix to this rule.
In the event the centers for medicare and medicaid services
				makes subsequent adjustments to the medicare reimbursement rates under the
				medicare outpatient prospective payment system as implemented by the materials
				specified in paragraph (A)(10) of this rule, other than technical corrections,
				including but not limited to adjustments related to federal budget
				sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239,
				2 U.S.C.
				900 to
				907(d) as amended
				as of the effective date of this rule, the "applicable medicare reimbursement
				rate for the hospital outpatient service under the medicare outpatient
				prospective payment system" as specified in this paragraph will be determined
				by the bureau without regard to such subsequent adjustments.
(2) Services reimbursed via fee schedule.
			 These services will not be wage index adjusted.
(a) Services reimbursed via fee schedule to
			 which the bureau-specific payment adjustment factor will be applied.
Except as otherwise provided in paragraphs (A)(2)(b)(ii) and
				(A)(2)(b)(iii) of this rule, hospital outpatient services reimbursed via fee
				schedule under the medicare outpatient prospective payment system will be
				reimbursed under the applicable medicare fee schedule in effect as implemented
				by the materials specified in paragraph (A)(10) of this rule, plus the add-on
				payments set forth in paragraph (A)(4) of this rule, if applicable.
(b) Services reimbursed via fee
			 schedule to which the bureau-specific payment adjustment factor will not be
			 applied.
The following services will be reimbursed the lesser of the
				charges billed by the hospital for the allowed services rendered, the
				applicable fee schedule rates set forth in tables 2, 3, 4 and 5 of the appendix
				to this rule, or the rate the MCO contracted or negotiated with the
				hospital:
(i) Hospital outpatient
			 vocational rehabilitation services for which the bureau has established a fee
			 as set forth in table 2 of the appendix to this rule.
(ii) Hospital outpatient services reimbursed
			 via fee schedule under the medicare outpatient prospective payment system that
			 the bureau has determined will be reimbursed at a rate other than the
			 applicable medicare fee schedule in effect as implemented by the materials
			 specified in paragraph (A)(10) of this rule, for which the bureau has
			 established a fee as set forth in table 3 of the appendix to this
			 rule.
(iii) Hospital outpatient
			 services not reimbursed under the medicare outpatient prospective payment
			 system that the bureau has determined are necessary for treatment of injured
			 workers, for which the bureau has established a fee as set forth in tables 4
			 and 5 of the appendix to this rule.
(3) Services reimbursed at reasonable cost.
			 To calculate reasonable cost, the line item charge will be multiplied by the
			 hospital's outpatient cost to charge ratio from the medicare outpatient
			 provider specific file in effect as implemented by the materials specified in
			 paragraph (A)(10) of this rule. These services will not be wage index adjusted.
(a) Services reimbursed at reasonable cost to
			 which the bureau-specific payment adjustment factor will be applied.
Notwithstanding any other reimbursement methodology set forth
				in this rule, critical access hospitals will be reimbursed at one hundred one
				per cent of reasonable cost for all payable line items.
(b) Services reimbursed at reasonable cost to
			 which the bureau-specific payment adjustment factor will not be applied.
(i) Services designated as inpatient only
			 under the medicare outpatient prospective payment system.
(ii) Hospital outpatient services reimbursed
			 at reasonable cost as identified in tables 3 and 4 of the appendix to this
			 rule.
(4)
			 Add-on payments calculated using the applicable medicare outpatient prospective
			 payment system methodology and formula in effect as implemented by the
			 materials specified in paragraph (A)(10) of this rule. These add-on payments
			 will be applied after the application of the bureau-specific payment adjustment
			 factor.
(a) Outlier add-on payment. An
			 outlier add-on payment will be provided on a line item basis for partial
			 hospitalization services and for ambulatory payment classification reimbursed
			 services for all hospitals other than critical access hospitals.
(b) Rural hospital add-on payment. A rural
			 hospital add-on payment will be provided on a line item basis for rural sole
			 community hospitals, including essential access community hospitals; however,
			 drugs, biological, devices reimbursed via pass-through and reasonable cost
			 items will be excluded. The rural add-on payment will be calculated prior to
			 the outlier add-on payment calculation.
(c) Hold harmless add-on payment. A hold
			 harmless add-on payment will be provided on a line item basis to exempt cancer
			 centers and children's hospitals. The hold harmless add-on payment will be
			 calculated after the outlier add-on payment calculation.
(5) Providers not participating in the
			 medicare program.
Reimbursement for outpatient services provided by hospitals and
				distinct-part units of hospitals that do not participate in the medicare
				program will be calculated in accordance with the methodologies set forth in
				this rule, using the applicable FY24 urban or rural statewide average outpatient cost-
				to-charge ratio adopted by the medicare program pursuant to the federal rule
				referenced in paragraph (A)(10)(b) of this rule (the Ohio average cost-to-
				charge ratio will be used for hospitals outside the United States).
(6) Reimbursement for outpatient
			 services provided by "new hospitals" as defined in
			 42 C.F.R.
			 412.300(b) as published in
			 the October 1, 2023 Code of Federal Regulations shall be calculated
			 in the same manner as provided under paragraph (A)(5) of this rule.
(7) For purposes of this rule, hospitals are
			 to report the applicable outpatient revenue codes for accommodation and
			 ancillary services set forth in table 7 of the appendix to this rule.
(8) For purposes of this rule, coverage
			 status for designated hospital outpatient services is set forth in table
			 9 of the
			 appendix to this rule.
(9)
									For purposes of this rule, services subject to always
			 and sometimes therapy editing are set forth in table 10 of the appendix to this
			 rule.
(10) For purposes of
			 this rule, the "applicable medicare reimbursement rate for the hospital
			 outpatient service under the medicare outpatient prospective payment system "
			 and the "medicare outpatient prospective payment system " will be determined in
			 accordance with the medicare program established under Title XVIII of the
			 Social Security Act, 79 Stat. 286 (1965),
			 42 U.S.C.
			 1395 to
			 1395lll as amended, as of the
			 effective date of this rule, as implemented by the following materials, which
			 are incorporated by reference:
(a) 42 C.F.R.
			 Part 419 as published in the October 1, 2023 Code of
			 Federal Regulations;
(b) Department
			 of health and human services, centers for medicare and medicaid services' "42
			 CFR Parts 405, 410,  416,
			 419, 424, 485 ,
			 488, 489 Medicare Program: Hospital Outpatient Prospective Payment and
			 Ambulatory Surgical Center Payment Systems ; Quality
			 Reporting Programs;  Payment 
										for Intensive Outpatient
			 Services in Hospital Outpatient Departments, Community Mental Health Centers,
			 Rural Health Clinics, Federally Qualified Health Centers, and Opioid Treatment
			 Programs; 
										Hospital Price
			 Transparency; Changes to Community Mental Health Centers Conditions of
			 Participation, Proposed Changes to the Inpatient Prospective Payment System
			 Medicare Code Editor; Rural Emergency Hospital Conditions of Participation
			 Technical Correction" final rule 88 Fed. Reg.
			 81540 -
			 82185
			 (2023).
(c)
			 The department of health and human services, centers for medicare and medicaid
			 services' hospital-specific cost-to-charge ratio information as of the October
			 2023
			 update to the department of health and human services, centers for medicare and
			 medicaid services' outpatient-provider specific file (OPSF).