Federal Register, Volume 75, Number 226, November 24, 2010, Pages 71519-72652 Page: 71,889
viii, 72651, iv p. ; 28 cm.View a full description of this periodical.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
Federal Register/Vol. 75, No. 226/Wednesday, November 24, 2010/Rules and Regulations 71889
payment system and should be based on
projected payments using the latest
available historical data without
adjustments for prior year outlier
payments. In this case, the 0.85 percent
is only an estimate made from CY 2009
claims for purposes of presenting an
impact of the change in the outlier
threshold in the regulatory impact
analysis. Although estimated outlier
payments for the current PPS year,
which appear in the impact tables,
frequently are below the 1 percent target
outlier spending percentage, as we
discuss below, we more often than not
pay slightly more than 1 percent of
aggregate total OPPS payments in
outlier payments in a given year. We
continue to believe that it is appropriate
to maintain the target outlier percentage
of 1.0 percent of estimated aggregate
total payment under the OPPS and to
have a fixed-dollar threshold so that
OPPS outlier payments are made only
when the hospital would experience a
significant loss for supplying a
particular service.
With respect to the commenter that
requested that we release the "actual"
payment percentages for CY 2007
through CY 2009, we note that we have
previously provided and continue to
provide estimated actual percentage
spending based on the claims data. In
the CY 2009 OPPS/ASC final rule with
comment period (73 FR 68592), using
CY 2007 claims, we found OPPS outlier
spending was 0.9 percent of the total
aggregated OPPS payment for CY 2007.
In the CY 2010 OPPS/ASC final rule
with comment period (74 FR 60426),
using CY 2008 claims, we found that
OPPS outlier spending was 1.2 percent
of the total aggregated OPPS payments
for CY 2008. As discussed earlier in this
section, using CY 2009 claims, we found
that OPPS outlier spending was 1.3
percent of the total aggregated OPPS
payments for CY 2009. We note that
actual outlier payments can only be
determined based on the claims data
available and setting a prospective
fixed-dollar outlier threshold without
accounting for changes in CCRs and
charges would potentially lead to
greater inaccuracy in establishing the
outlier fixed-dollar threshold. OPPS
outliers account for the financial risk
hospitals experience when providing an
extraordinarily costly and complex
service, and account for the resource
utilization in the methodology by
identifying the costs associated with
providing services on each claim. We
note that visit intensity data and
diagnoses data are not incorporated into
the calculation of the threshold becausethese are not components of OPPS
payments or our longstanding policy for
determining outlier eligibility and
payment amount.
3. Final Outlier Calculation
For CY 2011, we are applying the
overall CCRs from the July 2010
Outpatient Provider-Specific File with a
CCR adjustment factor of 0.9910 to
approximate CY 2011 CCRs to charges
on the final CY 2009 claims that were
adjusted to approximate CY 2011
charges (using the final 2-year charge
inflation factor of 1.0988). These are the
same CCR adjustment and charge
inflation factors that were used to set
the IPPS fixed-dollar threshold for the
FY 2011 IPPS/LTCH PPS final rule (75
FR 50427 through 50431). We simulated
aggregated CY 2011 hospital outlier
payments using these costs for several
different fixed-dollar thresholds,
holding the 1.75 multiple threshold
constant and assuming that outlier
payment would continue to be made at
50 percent of the amount by which the
cost of furnishing the service would
exceed 1.75 times the APC payment
amount, until the total outlier payments
equaled 1.0 percent of aggregated
estimated total CY 2011 OPPS
payments. We estimate that a fixed-
dollar threshold of $2,025, combined
with the multiple threshold of 1.75
times the APC payment rate, will
allocate 1.0 percent of estimated
aggregated total OPPS payments to
outlier payments.
In summary, for CY 2011, we will
continue to make an outlier payment
that equals 50 percent of the amount by
which the cost of furnishing the service
exceeds 1.75 times the APC payment
amount when both the 1.75 multiple
threshold and the final fixed-dollar
$2,025 threshold are met. For CMHCs, if
a CMHC's cost for partial hospitalization
services, paid under either APC 0172 or
APC 0173, exceeds 3.40 times the
payment for APC 0173, the outlier
payment is calculated as 50 percent of
the amount by which the cost exceeds
3.40 times the APC 0173 payment rate.
We estimate that this threshold will
allocate 0.02 percent of outlier
payments to CMHCs for PHP outlier
payments.
4. Outlier Reconciliation
In the CY 2009 OPPS/ASC final rule
with comment period (73 CFR 68599),
we adopted as final policy a process to
reconcile hospital or CMHC outlier
payments at cost report settlement for
services furnished during cost reporting
periods beginning in CY 2009. OPPS
outlier reconciliation more fully ensures
accurate outlier payments for thosefacilities whose CCRs fluctuate
significantly relative to the CCRs of
other facilities, and who receive a
significant amount of outlier payments
(73 FR 68598). As under the IPPS, we
do not adjust the fixed-dollar threshold
or the amount of total OPPS payments
set aside for outlier payments for
reconciliation activity because such
action would be contrary to the
prospective nature of the system. Our
outlier threshold calculation assumes
that overall ancillary CCRs accurately
estimate hospital costs based on the
information available to us at the time
we set the prospective fixed-dollar
outlier threshold. For these reasons, as
we stated in the proposed rule, and have
previously discussed in the CY 2009
OPPS/ASC final rule with comment
period (73 FR 68596), we are not
incorporating any assumptions about
the effects of reconciliation into our
calculation of the OPPS fixed-dollar
outlier threshold.
Comment: One commenter asked that
CMS report the amount of outlier
reconciliation activity suggesting that, if
the reconciled amounts are significant,
these amounts should be factored into
the annual fixed-dollar outlier threshold
in the future. One commenter supported
the current criteria for when OPPS
outlier payments would go through a
reconciliation process.
Response: We appreciate the
commenter's support for our policy. As
we discuss above, we do not take outlier
reconciliation amounts into account in
our projections of future outlier
payments. It is difficult to predict the
specific hospitals that will have CCRs
and outlier payments that may be
reconciled in any given year. We also
note that reconciliation occurs because
hospitals' actual CCRs for the cost
reporting period are different from the
interim CCRs used to calculate outlier
payment when a bill is processed. Our
fixed-dollar threshold calculation
assumes that CCRs accurately estimate
hospital costs based on information
available to us at the time we set the
prospective fixed-dollar threshold.
Furthermore, we do not believe that
estimating the fixed-dollar threshold to
account for the amount of payment that
is recovered or removed as a result of
outlier reconciliation in any given year
would necessarily result in a more
accurate estimate of outlier payments or
a more accurate calculation of the fixed-
dollar threshold for outlier payment for
the prospective payment year. In our
experience modeling the OPPS fixed
dollar threshold each year, changing the
CCRs for a handful for hospitals would
not typically result in enough change in
estimated total outlier payments tochange the modeled fixed dollar
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
United States. Office of the Federal Register. Federal Register, Volume 75, Number 226, November 24, 2010, Pages 71519-72652, periodical, November 24, 2010; Washington D.C.. (https://digital.library.unt.edu/ark:/67531/metadc52807/m1/378/: accessed April 24, 2024), University of North Texas Libraries, UNT Digital Library, https://digital.library.unt.edu; crediting UNT Libraries Government Documents Department.