Healthcare is an ever-changing industry, and in 2023, CMS made notable changes — some lauded, some contested.
CMS policies affect many issues healthcare leaders and physicians are most passionate about, such as reimbursement and practice capabilities.
Here are 15 policy changes made by CMS last year to know going into 2024, listed in chronological order:
1. CMS implemented a policy that provides complexity adjustments for certain ASC procedures.
Previously, add-on codes did not receive more reimbursement when bundled with primary codes. With this new policy, Medicare will provide adjustments to the payment rate to account for the costs of specific services.
2. The agency issued a final rule to help streamline Medicare Advantage and Part D prior authorizations. The update focused on coordinated care plans and establishing utilization management committees to review policies annually to ensure prior authorization is used appropriately.
3. CMS launched a value-based primary care model in eight states through the Center for Medicare and Medicaid Innovation that will seek to create more coordinated care for rural and underserved populations.
4. The agency approved a state plan amendment permitting South Dakota to expand Medicaid coverage to adults with incomes up to 133% of the federal poverty level.
5. It released the fifth evaluation report of the Oncology Care Model, designed to provide higher quality and more coordinated oncology care at the same or lower cost to Medicare.
6. It also released its fifth evaluation report of the Comprehensive Care for Joint Replacement Model, launched in 2016 to determine whether an episode-based payment model for lower extremity joint replacement can lower payments while maintaining or improving quality.
7. The agency added a Stark law waiver for physician owners of independent free-standing emergency departments that served Medicare patients during the COVID-19 pandemic.
8. The Consolidated Appropriations Act of 2023 updated exceptions to Stark law and anti-kickback law that will allow hospitals and healthcare providers to improve mental health services for physicians. The law issues a new exception for physician wellness programs offered by healthcare entities, including ASCs, hospitals and physician practices.
9. CMS proposed maintaining the waiver of geographic and originating site restrictions related to telehealth through the end of 2024. The waiver will allow Medicare beneficiaries to connect with physicians anywhere in the U.S. from home.
10. CMS also introduced a new care model aiming to help states improve healthcare costs, quality and efficacy for their populations. CMS will give up to $12 million to up to eight states to redesign statewide healthcare delivery to improve care quality and efficacy to reduce health disparities and improve health outcomes.
11. HHS' Office of Inspector General confirmed broad protection of employee safe harbor under anti-kickback laws in a recent ruling. The OIG was considering a proposed bonus pay for physician employees of a physician practice that operates two ASCs. Under the proposed methodology, physicians who performed procedures at the ASCs would receive 30% of the net profits from the ASC facility fee.
The ruling stated that although the methodology would violate anti-kickback law, it would be protected under the statutory exception and regulatory safe harbor for employees, given that the physician recipients were employees of the practice.
12. CMS announced plans to reduce overall physician pay by 1.25% in 2024 and update the conversion factor to $32.74, a 3.4% decrease over last year.
13. The final payment rule for ASCs in 2024 was finalized at 3.1%. Even with the improved rate, physicians feel as though ASC payments still are not fair under Medicare.
This payment ruling has been met with disappointment by providers, even inviting lawsuits against CMS and HHS.
14. The agency also finalized its extension of the interim period using the same pay update factor for ASCs and HOPDs through 2025. This means ASC payment rates will align with the hospital market basket rate for the next two years.
15. The ASC payment system rule added 11 procedures to the ASC-covered list:
- 21194 (Reconstruct lower jaw w/graft)
- 21195 (Reconstruct lower jaw w/o fixation)
- 23470 (Reconstruct shoulder joint)
- 23472 (Reconstruct shoulder joint)
- 27006 (Incision of hip tendons)
- 27702 (Reconstruct ankle joint)
- 29868 (Meniscal transplant knee w/scope)
- 33289 (TCAT implantation of wireless pulmonary artery pressure sensor)
- 37192 (Insertion of intravascular vena cava filter)
- 60260 (Repeat thyroid surgery)
- C9734 (Ultrasound ablation/therapeutic intervention, other than uterine leiomyomata)