ASTRO's Health Policy Payment Systems Committee executes any liaison or outreach work done by ASTRO in coordination with the federal government. This includes work done with the Centers for Medicare and Medicaid Services, the agency responsible for administering Medicare and Medicaid. ASTRO works with CMS on policy issues affecting radiation oncology coverage, reimbursement, fraud and abuse issues, and monitors the following CMS regulations very closely:
Medicare Physician Fee Schedule (MFS) – Both physicians and nonphysicians, that practice in a freestanding center or private practice and provide services for Medicare beneficiaries, are reimbursed by CMS under the MFS. CMS publishes a Proposed and a Final MFS Rule each year that addresses certain provisions, and changes to Medicare Part B payment policy. ASTRO submits comment letters to CMS on those issues related to radiation oncology, to advocate for fair and accurate reimbursement for the services that radiation oncologists provide.
Hospital Outpatient Prospective Payment System (HOPPS) – A physician that provides services to Medicare beneficiaries while practicing in a hospital outpatient setting is reimbursed for the professional component of that service through the Medicare Physician Fee Schedule. However, the technical component associated with that procedure is reimbursed through a prospective payment system. All services paid under the PPS are classified into groups called Ambulatory Payment Classifications, or APCs, each of which have an established payment rate. Services in each APC are similar clinically and in terms of the resources they require. CMS publishes a Proposed and a Final HOPPS rule each year that addresses certain statutory requirements and changes associated with this payment system, as well as implements certain provisions related to the Modernization Act of 2003 and the Deficit Reduction Act of 2005. ASTRO submits comment letters to CMS on those issues related to radiation oncology, to advocate for fair and accurate reimbursement for the services that radiation oncologists provide in the hospital setting.
Other Payment System Regulations Published by the Centers for Medicare and Medicaid Services:
Ambulatory Surgical Centers (ASCs) -
Skilled Nursing Facilities (SNFs) -
Section 4432(a) of the Balanced Budget Act of 1997 modified how payment is made for Medicare skilled nursing facility services. Effective with cost reporting periods beginning on or after July 1, 1998, SNFs are no longer paid on a reasonable cost basis or through low volume prospectively determined rates, but rather on the basis of a prospective payment system). The PPS payment rates are adjusted for case mix and geographic variation in wages and cover all costs of furnishing covered SNF services (routine, ancillary and capital-related costs).
Update on Medicare claims processing
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