In 2019, the Centers for Medicare & Medicaid Services (CMS) adopted a method to control unnecessary increases in the volume of the clinic visit services furnished in excepted off-campus provider-based departments (PBDs), defined as a hospital outpatient department, that is farther than 250 yards from the main campus and billed under the Medicare Hospital Outpatient Prospective Payment System (OPPS) prior to November 2, 2015, by paying them a physician-equivalent rate, which is lower than the OPPS rate. This method is intended to prevent Medicare and beneficiaries from paying significantly more in the excepted off-campus PBD setting than in the physician office setting. Click here for more information.
In the Medicare Hospital OPPS Calendar Year 2026 proposed rule,
- CMS seeks comments on its proposal to reimburse for drug administration services furnished in excepted off-campus PBDs at a physician-equivalent rate. Drug administration includes the intravenous or intramuscular administration of a range of medicines. This proposal would not be budget neutral. CMS estimates it would reduce OPPS spending by $280 million, with $210 million of the savings accruing to Medicare, and $70 million saved by Medicare beneficiaries in the form of reduced beneficiary coinsurance.
- CMS also request information on whether they should expand their method to control unnecessary increases in the volume of clinic visit services to on-campus hospital outpatient departments. Specifically, they seek input on the impacts on providers and beneficiaries, including those in rural areas, if Medicare paid on-campus PBDs a physician-equivalent rate that is 40 percent of the OPPS rate for clinic visit services.
Comments are due by September 15.