Resources

Client Alerts, News Articles, Blog Posts, & Multimedia

Everything you need to know about BMD and the industry.

CMS to Once Again Reprocess Outpatient Clinic Claims

Client Alert

Overview:

The Hospital Outpatient Prospective Payment System (OPPS) Rule was passed in November 2018, which was intended to prevent the Centers for Medicare and Medicaid Services (CMS) from paying more for services rendered in outpatient settings than what they paid for the same services rendered in physician offices that are simply owned by hospitals or health systems.[1]

The Rule set payment rates for these services at “excepted” off-campus provider-based departments (those facilities that were excepted from reimbursement reductions under the Bipartisan Budget Act of 2015) at the same rate for non-excepted provider-based departments (PBDs) pursuant to the Physician Fee Schedule (PFS). However, in 2019, the reimbursement rate for services at these excepted facilities was set at 70%, and in 2020, just 40%.[2]  

The American Hospital Association (AHA) then sued CMS in the U.S. District Court for the District of Columbia in 2019 over the reimbursement reductions, and the Court ruled in favor of the AHA. As a result of the decision, CMS reprocessed the 2019 claims at the full 100% rate.[3]

Reprocessing Claims:

In 2020, however, the U.S. Court of Appeals for the D.C. Circuit reversed the district court’s decision. Pursuant to the reversal, starting November 1, 2021, CMS will once again begin reprocessing claims at excepted PBDs for outpatient claims to ensure that the services are reimbursed at the 70% rate for services rendered between January 1, 2019, and December 31, 2019.[4]

Conclusion:

As a result, excepted PBD providers will now have to refund the difference in coinsurance either to patients or insurers who paid an increased amount in cost-sharing when reimbursement was set at 100%, to reflect the reduction.[5]

CMS notes that providers do not need to take any other action as they reprocess claims.[6]  But providers should be aware of this reprocessing.

If you have any questions about how reprocessing will work or questions regarding issuing refunds, please contact Healthcare and Hospital Law Member Amanda Waesch at alwaesch@bmdllc.com. Special thanks to Rachel Stermer for her assistance in this client alert.

[1] CMS, Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments: Payment Update, (Sept. 9, 2021) https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2021-09-09-mlnc#_Toc82072549.

[2] Id.

[3] Id.

[4] Id.

[5] Id.

[6] Id.


Corporate Transparency Act Overhauled: U.S. Entities No Longer Required to Report

The Department of Treasury has issued an interim final rule significantly altering the Corporate Transparency Act (CTA). As of March 21, 2025, all U.S.-created entities and their beneficial owners are exempt from reporting requirements. Only non-U.S. entities registered to do business in the U.S. must still report, but they are not required to disclose U.S. citizen owners. Business owners should stay informed on these changes and consult legal counsel for compliance guidance.

ODM to Implement Medicaid Work Requirements: What Providers and Medicaid Expansion Recipients Need to Know

The Ohio Department of Medicaid (ODM) has submitted a waiver to impose work requirements for Medicaid expansion recipients. If approved, the new eligibility criteria will take effect on January 1, 2026. A federal public comment period is open until April 7, 2025.

Ohio Appellate Court Rules in Favor of Gender-Affirming Care

On March 18, 2025, the 10th District Court of Appeals in Franklin County ruled that Ohio’s House Bill (HB) 68, which restricts puberty blockers and hormone therapy for minors seeking gender-affirming care, violates the Health Care Freedom Amendment and is therefore unenforceable. The court found that the law unlawfully interferes with parental rights and medical decision-making. The case, Moe v. Yost, has been remanded, and Ohio Attorney General Dave Yost intends to appeal.

HHS Revokes Public Comment Requirement on Certain Policy Changes

The U.S. Department of Health and Human Services (HHS) has revoked the Richardson Waiver, eliminating the requirement for public notice and comment on certain policy changes. This decision allows HHS to implement new policies more quickly, potentially affecting healthcare funding rules like Medicaid work requirements. While it speeds up policymaking, it also reduces opportunities for stakeholder input, raising concerns over transparency and unintended consequences for healthcare providers, states, and patients.

Don't Get Caught Dazed and Confused: Another Florida Court Weighs in on Employer Obligations to Accommodate Medical Marijuana Use

A Florida trial court ruled in Giambrone v. Hillsborough County that employers may need to accommodate off-duty medical marijuana use under the Florida Civil Rights Act (FCRA). This contrasts with prior rulings and raises new compliance challenges for employers. With the case on appeal, now is the time to review workplace drug policies.