CMS to reprocess certain 2019 outpatient claims due to court ruling

Starting by July 1, the Centers for Medicare & Medicaid Services will reprocess calendar year 2019 claims for hospital outpatient clinic visit services provided in off-campus provider-based departments excepted under the Bipartisan Budget Act of 2015 to pay them at 70% of the outpatient prospective payment system rate, the same rate as non-excepted departments, the agency announced today.

AHA members will receive a Special Bulletin with more information.

A federal judge in 2019 ruled that CMS exceeded its statutory authority when it reduced payments for hospital outpatient clinic visit services provided in off-campus provider-based departments excepted under the act, siding with AHA and other hospital organizations that challenged the cut.

CMS reprocessed the claims starting in January 2020 to repay the cut. An appeals court then reversed the district court ruling. AHA will ask the U.S. Supreme Court to review the appeals court decision.