Back to the Future: Restated Drug and Biological Payment Rates
Published date: March 29, 2021
Each quarter, CMS recalculates the payment rates for drugs based upon data electronically submitted by the manufacturers. Occasionally a manufacturer reports an average sales price (ASP) incorrectly, or CMS makes an error in blending multiple manufacturer submissions.
However when audits occur, or providers request a recalculation, CMS will “restate” payment rates for both hospital outpatient departments and ambulatory surgery centers. These are posted each quarterly at the following CMS Locations:
OPPS restated payment rates
ASC restated payment rates
So, what do we do with these tables?
In general, there are usually only a handful of HCPCS codes with changed rates, but sometimes they involve multiple quarters. We’ve taken the April 2021 restated payment rates and compared them to the previous quarters. The columns in red were added from other CMS documents, or are calculated differences.
Typically, claims with HCPCS codes with restated payment rates are not automatically re-processed. Providers need to bring the claims to the MACs attention and rebill the claim. Since payment rates can generate additional or lower payments, and there are costs associated with rebilling claims, pharmacy should review with compliance and revenue integrity and establish a policy that establishes a minimum cost threshold or percentage to consider re-billing and it should be uniformly applied for positive or negative changes in reimbursement. For example, some facilities may only do further review if the changes is greater than or less than 10%.
In reviewing the April restated payment rates, it appears that most impacted HCPCS codes do not have a significant difference.
But let’s apply the same process to the January 2021 update. Again, we’ve matched the long descriptors and original payment rates from other CMS files, but we see a different result!
Look at the radiopharmaceutical that is reported with HCPCS Code A9600: Strontium sr-89 chloride, therapeutic, per millicurie. The original payment was around $2000, but the corrected rate is almost $4000, a difference of $2000. And remember this is “per millicurie”. In reviewing the FDA information, the recommended dose of Metastron™ is 148 MBq, 4 mCi, administered by slow intravenous injection (1-2 minutes).
So the difference in payment rate from the original payment is almost $8000 per treatment!
Although this radiopharmaceutical may not be given often, it illustrates that restated payment rates can be significant! Who in your organization reviews these adjustments every quarter and makes the decision to rebill when the difference is important to the bottom line?
1. Pharmacy, Compliance and Revenue Cycle should develop a policy and procedure to establish which team will review the quarterly restated drug and biological payment rate files from CMS and request re-billing when differences are significant.
2. Revenue Cycle should review outpatient claims billed with dates of service between October 1, 2020 and December 31, 2020 for HCPCS code A9600 for potential rebilling to Medicare or any other payer who establishes payment rates based upon Medicare. Rebilling should be done within the payer-established timely filing limits (1 year for Medicare).