June 28, 2018

ACR Criticizes Surprise Billing Provisions in Medicare IPPS Proposed Rule

On June 25, 2018, the American College of Radiology (ACR) submitted written comments to the Centers for Medicare & Medicaid Services (CMS) on the Inpatient Prospective Payment System (IPPS) proposed rule for Calendar Year 2019.

In the proposal, CMS addresses requirements for hospitals to publicly disclose its list of standard charges and solicits comments on how that list could most effectively be made available to patients. However, in this section CMS conflates the issue of insufficient hospital price transparency to also express concerns about patients receiving “surprise bills,” including bills for out-of-network medical services from radiologists.

The ACR’s comments support enhanced hospital price transparency in the IPPS proposed rule but make the point that surprise billing is primarily an issue for private insurers, not Medicare. Surprise bills typically arise when an individual receives planned care from an in-network provider, but other out-of-network providers also become involved with diagnosis and/or treatment. CMS’ payment systems, however, clearly outline the rules for participating, non-participating and opt-out-providers and cover mandates for a defined, transparent patient co-payment. As a result, the College stressed that discussion of surprise bills is largely not applicable to Medicare and outside the scope of the IPPS rulemaking process.

Relating to provisions on the proposed rule, the ACR met with CMS earlier this year to request that it delete CT and MR cost centers from both the Inpatient and Outpatient Prospective Payment Systems (OPPS). Although CMS elected not to respond to the College’s request, the ACR’s comments on the IPPS rule lay the groundwork for how we will comment on CT and MRI cost centers in the upcoming OPPS proposed rule.

If CMS does not propose to delete the separate cost centers in the forthcoming OPPS rule, the ACR anticipates the agency will then propose full implementation of CT and MRI cost centers as of Jan. 1, 2019. Such an outcome would lead to unreasonably low pricing of CT and MRI performed in hospital settings. And, the resulting, unsustainable, hospital outpatient department prices would ultimately affect Medicare payments in the office setting as well, due to stipulations in the Deficit Reduction Act of 2005 that require Medicare to pay the lower of the HOPPS or the technical component of the Medicare Physician Fee Schedule(MPFS).

The ACR also commented on the future direction of the hospital-specific Promoting Interoperability Program (previously the Electronic Health Record [EHR] Incentive Program). We encouraged CMS to protect the free flow of clinical information exchanged between users of hospital EHR systems and external medical imaging providers. Specifically, the ACR recommended that eligible hospitals caught applying prohibited information-blocking practices or determined to be in violation of interoperability requirements should fail the Promoting Interoperability Program for the year when the offenses occurred, and thus should be subject to the corresponding negative payment adjustments. The ACR indicated that ensuring appropriate exchange of orders and reports between referring clinicians using hospital EHR systems and unaffiliated imaging providers would empower choice and competition.

The IPPS final rule is due to be released in a few months. The ACR will keep members posted on the eventual outcomes. For more information in the meantime, please contact ACR Economics Advisor Pam Kassing (pkassing@acr.com).