Medicare Issues 2025 Payment Policy Proposals for Outpatient Hospital Departments

July 17, 2024

The Centers for Medicare & Medicaid Services (CMS) issued the outpatient prospective payment system (OPPS) proposed rule [PDF], which proposes hospital outpatient departments (HOPDs) to receive a payment update of 2.6% in 2025. This is an increase of $5.2 billion over 2024 payments to the sector, making total payments to HOPDs in 2025 an estimated $88.2 billion.

This rule primarily impacts audiologists because their services are paid through the OPPS whereas most speech-language pathology services provided in this setting are exempt from the OPPS and are instead paid under the physician fee schedule.

Learn more about the other proposals outlined in the rule below, including updates on:

• Telehealth Services
• Personal Protective Equipment
• Hospital Inpatient Quality Reporting
• Hospital Outpatient Quality Reporting
• Medicaid Continuous Eligibility
• Prior Authorization
• Ambulatory Payment Classifications

Telehealth Services

In 2023, CMS generated significant concern about coverage for telehealth services provided by speech-language pathologists (SLPs) in HOPDs by providing a different interpretation for the continuation of telehealth flexibilities than other Part B settings in 2023 and beyond. Through extensive advocacy by ASHA and other stakeholders, CMS finalized a policy for 2023 and 2024 that would allow HOPDs to continue billing for telehealth services as they had during the COVID-19 public health emergency, essentially leaving telehealth coverage unchanged through the end of this year.

In this rule, CMS is proposing to align telehealth coverage policies for speech-language pathology services provided in HOPDs to those under the physician fee schedule to provide continuity of Part B coverage policies across settings. Unfortunately, because audiology services provided in HOPDs are paid under the OPPS and not the fee schedule, this flexibility will not extend to these services. However, formalizing this policy will ensure HOPD patients receiving speech-language pathology services via telehealth can continue to do so as long as it's allowed under state and federal law.

Next Steps for ASHA: ASHA will comment in support of ensuring Part B telehealth services are covered equitably regardless of practice setting. We will also continue to push Congress to allow audiologists and SLPs to provide telehealth services permanently.

What You Can Do: The flexibility to cover audiology and speech-language pathology under the fee schedule will expire at the end of 2024 without Congressional action. Please contact your members of Congress and encourage them to allow audiologists and SLPs to continue billing for telehealth services permanently.

For more information on Medicare coverage of audiology and speech-language pathology telehealth services, please visit ASHA's website.

Request for Information on Cost of and Payment Adjustments for Personal Protective Equipment (PPE)

CMS currently provides a payment adjustment to help hospitals offset the cost of PPE, in particular N95 respirators. In the proposed rule, CMS seeks feedback if it should allow additional forms of PPE to qualify for this payment adjustment such as nitrile gloves.

Next Steps for ASHA: ASHA is consulting with members to determine if there are additional forms of PPE used by audiologists and SLPs, such as face shields and clear face masks, that should be considered for this payment adjustment and will comment accordingly.

Hospital Inpatient Quality Reporting (IQR) Program

The Hospital IQR Program is a pay-for-reporting quality program that incentivizes quality improvement and penalizes hospitals that do not submit quality data or meet program requirements. CMS is proposing to continue voluntary reporting of the core clinical data elements (CCDEs), Hospital-Wide Readmission (HWR), and Hybrid Hospital-Wide Standardized Mortality (HWM) measures for the performance period of July 1, 2023, through June 30, 2024, impacting the FY 2026 payment determination for the Hospital IQR Program.

What You Can Do: Educate your facility on the direct link between audiology and speech-language pathology services and reduced hospital readmission and mortality outcomes. Here are a couple helpful resources:

• Teh, W.H., Smith, C.J., Barlas, R.S., Wood, A.D., Bettencourt-Silva, J.H., Clark, A.B., Metcalf, A.K., Bowles, K.M., Potter, J.F., & Myint, P.K. (2018). Impact of stroke-associated pneumonia on mortality, length of hospitalization, and functional outcome. Acta Neurologica Scandinavica, 138(4), 293-300. 10.1111/ane.12956
• Bolinger, C., & Dembowski, J. (2022). Speech language pathology consultations and medical outcomes for patients with aspiration pneumonia. Journal of Medical and Health Studies, 3(3), 45-58.

Hospital Outpatient Quality Reporting (OQR) Program

The Hospital OQR Program is a pay-for-reporting quality program for hospital outpatient departments that requires hospitals to meet quality reporting requirements or else they are penalized with a 2% reduction in their annual payment update.

CMS is proposing to remove two measures related to low back pain and cardiac imaging and adopt four new measures:

1. Hospital Commitment to Health Equity (HCHE) measure beginning with the CY 2025 reporting period/CY 2027 payment determination
2. Screening for Social Drivers of Health (SDOH) measure beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination
3. Screen Positive Rate for Social Drivers of Health (SDOH) measure, beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination.
4. Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance measure (Information Transfer PRO-PM) beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028

ASHA supports measures that ensure health equity and SDOH are appropriately recognized as impacting outcomes of care for patients.

Lastly, CMS is proposing to require that Electronic Health Record (EHR) technology be certified to all Electronic Clinical Quality Measures (eCQMs) in this program to ensure that hospitals can accurately capture and report data for all eCQMs in the measure set.

Medicaid Changes to Maintain Continuous Eligibility

CMS proposes a change related to continuous eligibility for children 19 and under covered by Medicaid to implement a requirement of the Consolidated Appropriations Act (CAA) of 2023 (Public Law 117-328). Specifically, the proposal would require 12 months of continuous eligibility. For example, if a child qualified for Medicaid on July 1, 2024, and then in December 2024 no longer met the state Medicaid eligibility requirements, the child would remain on Medicaid until June 30, 2025. ASHA is pleased with this proposed change, which is a positive and significant step towards maintaining access to and continuity of care for children covered under Medicaid.

Changes to Prior Authorization Policies

Current regulations require that HOPDs seek prior authorization from Medicare Administrative Contractors (MACs) for select services, including botulinum toxin injections (BIT). Under the policy, MACs have 10 business days to respond to non-urgent requests and 2 business days to respond to expedited requests. However, in a separate final rule associated with interoperability and prior authorization requirements for Medicare Advantage Plans, applicable integrated plans, CHIP FFS programs, Medicaid managed care plans, and CHIP managed care entities, CMS set prior authorization determinations at 7 calendar days and within 72 hours for expedited requests.

ASHA is pleased with CMS's proposal to align the non-urgent request determination timelines for HOPDs with those outlined in the interoperability and prior authorization final rule from 10 business days to 7 calendar days. This should improve HOPD prior authorization requests so they are delivered sooner than under the current timeframes; thereby shortening the wait for patients to receive medically necessary care.

However, it is not changing the timeframe for expedited requests because in some cases 2 business days means the decision will come more quickly than 72 hours whereas in other cases 72 hours is faster than 2 business days. For example, an expedited request made on Friday might be made faster under the 72-hour timeframe than the 2 business day timeframe. But requests made during the week, such as on a Tuesday, would be made more quickly under the 2 business day timeframe.

Next Steps for ASHA: ASHA will submit comments supporting the alignment of prior authorization policies across programs and payers whenever possible to ensure timely access to care and reduce administrative burden for our members.

Changes to the Ambulatory Payment Classifications (APCs)

ASHA analyzed the proposed APCs that include audiology codes and there were no proposed changes for 2025.

What's Next?

ASHA will submit comments in advance of the September 9, 2024 deadline. The final rule will likely be issued in early November for implementation on January 1, 2025.

We encourage all members to join us in the fight to ensure audiologists and SLPs continue to be able to bill for telehealth services permanently. Take action today!

Resources

• CMS OPPS Proposed Rule Fact Sheet
• CMS OPPS Resource Center
• ASHA OPPS Resource Center

Questions?

Please contact ASHA's health care and education policy team a [email protected].