2021 IPPS Proposed Rule

The following is a summary of the following: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2021 Rates; Quality Reporting and Medicare and Medicaid Promoting Interoperability Programs Requirements for Eligible Hospitals and Critical Access Hospitals, to be published in the May 29, 2020 Federal Register.

Inpatient hospital rates

对于在住院患者预期支付系统(IPPS)下付费的普通急性护理医院,成功参与了医院住院患者质量报告(IQR)计划,并且是有意义的电子健康记录(EHR)用户,建议增加的运营支付率约为2.6%. The 2.6% is equal to the market basket rate increase of 3.0%, less the proposed multifactor productivity (MFP) adjustment of -0.4%. 非EHR用户或未参与IQR计划的供应商将在其基本费率上获得额外的折扣.

CAR T-Cell reimbursement

医疗保险和医疗补助服务中心(CMS)正提议创建一种新的MS-DRG用于嵌合抗原受体T细胞(CAR - T)治疗,其报销率将高于任何其他MS-DRG. CAR - T治疗目前被包括在一个明显较低权重的DRG中,但有资格获得一项新技术附加费用(NTAP)。. Please note that the NTAP eligibility expires after FY 2020.

DRG change requests

Hospitals have the opportunity each year to request that CMS review the DRG classifications. The deadline to request these changes has been November 1 of each year. However, due to the time it takes for these reviews, CMS将要求更改的截止日期推迟到每年的10月20日,以便有更多的时间审查和考虑任何更改.

DRG relative weight methodology change

CMS建议不再使用医院的毛额(来自成本报告和索赔数据)作为基础DRG重量计算的一部分. CMS recognizes that the chargemaster (i.e., gross charges) rates do not typically reflect hospitals’ true market costs. As such, CMS is proposing that, for cost report periods ending on or after January 1, 2021, hospitals would report on new Medicare cost report forms median negotiated rates by DRGs for 2 groups of patients:

  1. Patients insured by Medicare Advantage (MA) plans, and
  2. Patients insured by all third-party payers, including MA plans.

Bad debts

CMS has proposed several changes to “clarify, update and codify certain longstanding Medicare bad debt principles” into the regulations. These proposed changes would be effective for cost reporting periods beginning before, on, and after the effective date of this rule (which would be October 1, 2020).

  1. CMS proposes to amend CFR §413.89(e)(2) by adding a new paragraph (e)(2)(i) to define, for Medicare bad debt purposes, 非贫困受益人是指没有被国家医疗补助机构确定为“绝对或医疗上有需要”的受益人,不能从医疗补助机构获得医疗援助, and has not been determined to be indigent by the provider for Medicare bad debt purposes.
  2. CMS proposes to amend CFR §413.89(e)(2)增加新的(e)(2)(i)(a)款,以规定对非贫困受益人的合理收款努力要求必须与提供方的努力类似, and/or the collection agency acting on the provider’s behalf, puts forth to collect comparable amounts from non-Medicare patients. These efforts must include the issuance of a bill to the beneficiary or the party responsible for the beneficiary’s personal financial obligations on or before 120 days after: (1) the date of the Medicare remittance advice; or (2) the date of the remittance advice from the beneficiary’s secondary payer, if any; whichever is latest. A provider’s reasonable collection effort usually also includes other actions such as subsequent billings, collection letters and telephone calls or personal contacts with the responsible party which, according to CMS, constitutes a genuine, rather than token, collection effort. Additionally, a provider must maintain and, upon request, furnish documentation to its contractor (i.e., MAC) that includes the provider’s bad debt collection policy which describes the collection process for Medicare and non-Medicare patients; the beneficiary’s account history documents which show the dates of various collection actions such as the issuance of bills to the beneficiary, follow-up collection letters, reports of telephone calls and personal contact, etc.; and the beneficiary’s file with copies of the bill(s) and follow-up notices.
  3. CMS proposes to amend CFR §413.89(e)(2)增加新的(e)(2)(i)(a)(5)(ii)款,规定当提供商在所需的最低120天催收努力期内收到部分款项时, 提供商必须继续托收工作,而收到部分款项的当天是新的托收期的第一天. For each subsequent partial payment received during a 120-day collection effort period, 提供商必须继续托收工作,而随后的部分付款收到之日是新托收期的第一天. 在120天的收集期间结束时,如果在这连续120天内没有收到任何付款,提供商可以结束收集工作.
  4. CMS proposes to amend CFR §413.89(e)(2)增加新的(e)(2)(i)(a)段,以明确医疗服务提供者收取医疗保险免赔额和共同保险金额的努力必须与医疗服务提供者从非医疗保险患者收取可比金额的努力相似.
  5. CMS proposes to amend CFR §413.89(e)(2)增加新的(e)(2)(i)(a)(6)款,规定提供商必须遵守的要求,以确定提供商对非贫困受益人的合理收款努力.
  6. CMS proposes to amend CFR §413.89(e)(2)通过增加新的(e)(2)(ii)款,将贫困非双重资格受益人定义为医疗保险受益人,其被提供者确定为贫困且不符合医疗补助计划的分类或医疗需求.
  7. CMS proposes to amend CFR §413.89(e)(2)增加新的(e)(2)(ii)(A)款,规定确定受益人为贫困非双重资格受益人, 根据下列要求,服务提供方必须适用其惯常方法来确定受益人是否贫困:(1)受益人的贫困必须由服务提供方确定, not by the beneficiary; that is, a beneficiary’s signed declaration of their inability to pay their medical bills and/or deductibles and coinsurance amounts cannot be considered proof of indigence; (2) the provider must take into account a beneficiary’s total resources which includes, but is not limited to, an analysis of assets (only those convertible to cash and unnecessary for the beneficiary’s daily living), liabilities, and income and expenses. While a provider must take into account a beneficiary’s total resources in determining indigence, any extenuating circumstances that would affect the determination of the beneficiary’s indigence must also be considered; and (3) the provider must determine that no source other than the beneficiary would be legally responsible for the beneficiary’s medical bill; for example, a legal guardian.
  8. CMS proposes to amend CFR §413.89(e)(2) by adding new paragraph (e)(2)(ii)(B) to specify that as part of its determination of indigence, the provider must maintain and furnish, upon request to its Medicare contractor (i.e., MAC), documentation (for example, a确定贫困政策),说明确定贫困或医疗贫困的方法,并说明受益人的具体文件,以支持提供者beat365最新地址每个受益人的贫困或医疗贫困的文件.
  9. CMS proposes to amend CFR §413.89(e)(2) by adding a new paragraph (e)(2)(iii) to clarify and codify that, effective for cost reporting periods beginning on and before the effective date of this rule, to be considered a reasonable collection effort, 提供服务给双重资格的受益人的提供者必须确定是否国家的Title XIX医疗补助计划(或当地福利机构), (如适用)负责支付所有或部分受益人的医疗保险扣除和/或共保金额. To make this determination, 提供者必须向其医疗补助/标题XIX机构(或其当地福利机构)提交一份账单,以确定国家的成本分担义务,支付所有或部分适用的医疗保险扣除和共同保险.
  10. CMS proposes to amend CFR §413.89(b)(1) by adding new paragraph (b)(1)(i) to specify that for cost reporting periods beginning before October 1, 2020, 坏账是指在提供服务过程中产生或取得的应收帐款和应收票据中不能收回的数额. “Accounts receivable” and “notes receivable” are designations for claims arising from the furnishing of services, and are collectible in money in the relatively near future.
  11. CMS proposes to amend CFR §413.89(b)(1)增加新的(b)(1)(ii)段,以明确10月1日或之后开始的成本报告期间, 2020, bad debts, also known as “implicit price concessions,” are amounts considered to be uncollectible from accounts that were created or acquired in providing services. “Implicit price concessions” are designations for uncollectible claims arising from the furnishing of services, 可能在不久的将来以货币形式收回,并作为病人净收入的一部分记录在医疗服务提供者的会计记录中.
  12. CMS proposes to amend CFR §413.89(c) by adding new paragraph (c)(1) to specify that effective for cost reporting periods beginning before October 1, 2020 bad debts, charity, and courtesy allowances represent reductions in revenue.
  13. CMS proposes to amend CFR §413.89(c) by adding paragraph (c)(3) to specify that, effective for cost reporting periods beginning on or after October 1, 2020, 医疗保险坏账不能注销到合同备抵账户,但必须将无法收回的账户(坏账或隐性价格减让)记入费用账户。.

Wage index

CMS提议采用管理和预算办公室(OMB) 2018年对CBSA 2021年FFY描述的修订. CMS notes that using the revised OMB delineations, there would be some new CBSAs, urban counties that would become rural (none in New England), rural counties that would become urban (in New England, only rural CBSA 25011 – Franklin, MA would become urban CBSA 44140 – Springfield, MA and some existing CBSAs would be split apart (None in New England.

Also, in New England there was a technical name change of CBSA 25540- Hartford-West Hartford-East Hartford, CT which will become CBSA 25540 – Hartford – East Hartford – Middletown, CT.

In addition, 以下新英格兰地区目前被归为“卢格”农村地区的县将被重新划归城市地区.

  1. Litchfield, CT would be classified now as part of urban CBSA 35300 – New Haven-Milford, CT
  2. Oxford, ME would be classified now as part of urban CBSA 12580 – Lewiston-Auburn, ME
  3. Merrimack, NH would be classified now as part of urban CBSA 31700 – Manchester-Nashua, NH

As such, due to the varying impacts of the OMB’s revised delineations, CMS is proposing a one-year transition of a 5% cap on wage index decreases from FY 2020 across all hospitals, which it would implement in a budget-neutral manner.

CMS还建议继续执行“FFY 2020”政策,提高全国医院工资指数中最低四分之一的医院的工资指数值,并实行全面的预算中性调整.

Sole community hospital

CMS建议,对于申请成为唯一社区医院(SCH)之前有短期成本报告的医院, that CMS will use the hospital’s most recent 12 month or longer cost reporting period to define the service area.


CMS is proposing to expand the definition of a “displaced” resident. As such, CMS proposes to address two areas of concern regarding displaced residents.

The first is that CMS is proposing that rather than use the day prior to or the day of program or hospital closure, 关键的一天将是医院关闭的日子,这一天被公开宣布,作为医疗保险临时资金为流离失所的居民的关键日期.

第二项是一项提议,允许将医疗保险临时资金暂时转移给那些不在即将关闭的医院/关闭项目的人, but had intended to train at (or return to training at, in the case of residents on rotation) the closing hospital/closing program.

These changes would apply to the IME FTE cap transfers as well.

CMS还在着手修改其政策,要求接收流离失所居民的医院在其信函中包括流离失所居民的姓名和完整的社会保障号码. CMS计划要求接收医院只提供每位搬迁居民的姓名和社保号的后四位bet5365最新线路检测.

Disproportionate share hospital

CMS has proposed the uncompensated care costs (UCC) Pool to be $7,816,726,242. This is a decrease of $533,872,853 (6.39%) from the FFY 2020 final UCC pool of $8,350,599,096.  2020年FFY因子3将使用经审计的2017年成本报告工作表S-10数据进行计算(CMS表示,他们已审计了约65%的2017年工作表S-10时间表). CMS还提议,今后他们将继续使用单个年份的经审计的S-10数据来确定因素3,工作表S-10第30行将继续用作医院的无补偿护理费用的定义.

Long-term care hospitals

CMS has proposed a PPS based payment rate increase of 2.5% for those that qualify for the full update.

Low volume hospitals

Section 50204 of the Bipartisan Budget Act of 2018 reinstated Low Volume Add-On (LVA) program effective October 1, 2017 through September 30, 2022. In addition to reinstating and extending this provision, for FFY 2019 through the current expiration of this program in FFY 2022, 最初有资格获得这种附加补偿的最大医疗保险出院门槛从不足1增加,600个医疗保险出院(根据MedPar数据库,包括医疗保险A部分和C部分出院)的要求少于3,800 total discharges (Medicare and non-Medicare discharges). 另一项合格标准是,医院的地点必须离最近的(d)分院超过15英里.

For FFY 2021, 符合条件的医院必须向其MAC提交书面请求(我们建议询问您的MAC,以询问您是否可以通过电子邮件提交请求),其中包括足够的文件,以验证其满足超过15英里和出院要求.

If hospitals submit their request after September 1, then if the MAC approves the request, the hospital will begin to receive low volume add-on reimbursement payments within 30 days of the MAC determination.

Interoperability and electronic clinical quality measures (eCQM)

CMS正提议对医院住院患者质量报告(IQR)计划进行几项更改,其中包括在三年内增加eCQMs报告的季度数,直到从2021年报告期内开始,有四个季度的数据被公开报告eCQMs, and implementing several changes to the IQR validation process.



Eric Wetherell, CPA: Principal and Healthcare Advisory Group Leader

Marc Levy: Senior Manager, Healthcare Advisory Group

Denis Houle: Senior Manager, Healthcare Advisory Group

Pamela Cook: Senior Manager, Healthcare Advisory Group

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