4123-6-37.2 Payment of hospital outpatient services.

 

 

 

Rule Summary and Fiscal Analysis (Part A)

 

Bureau of Workers' Compensation

Agency Name

 

Aniko Nagy

Division                                                                  Contact

 

30 W. Spring St. Columbus OH 43215-0000                614-466-3293

Agency Mailing Address (Plus Zip)                                       Phone                     Fax

 

[e-mail]

Email

 

 

 

4123-6-37.2

Rule Number

AMENDMENT

TYPE of rule filing

Rule Title/Tag Line              Payment of hospital outpatient services.

RULE SUMMARY

1.  Is the rule being filed for five year review (FYR)? No

2.  Are you proposing this rule as a result of recent legislation? No

3.  Statute prescribing the procedure in accordance with the agency is required to adopt the rule: 119.03

4.  Statute(s) authorizing agency to adopt the rule: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05

5.  Statute(s) the rule, as filed, amplifies or implements: 4121.121, 4121.44, 4121.441, 4123.66

6.  State the reason(s) for proposing (i.e., why are you filing,) this rule:

The Bureau's hospital outpatient services reimbursement methodology is based on Medicare's Outpatient Prospective Payment System (OPPS), which is updated annually. Therefore, the Bureau must also annually update OAC 4123-6-37.2 to keep in sync with Medicare.

7.  If the rule is an AMENDMENT, then summarize the changes and the content

of the proposed rule; If the rule type is RESCISSION, NEW or NO CHANGE, then summarize the content of the rule:

For the hospital outpatient services with a date of service on or after May 1, 2016, the Bureau is recommending the following changes to OAC 4123-6-37.2:

1.  Adopt the 2016 hospital outpatient rates as published in Medicare's OPPS final rule.

2.  Apply a 306% Bureau payment adjustment factor to OPPS rates for children's hospitals.

3.  Apply a 167% Bureau payment adjustment factor to OPPS rates for all other hospitals.

8.  If the rule incorporates a text or other material by reference and the agency claims the incorporation by reference is exempt from compliance with sections

121.71 to 121.74 of the Revised Code because the text or other material is generally available to persons who reasonably can be expected to be affected by the rule, provide an explanation of how the text or other material is generally available to those persons:

This rule cites to a specific Federal Register citation and chapter of the Code of Federal Regulations, and to Federal Statutes as amended as of the effective date of the rule.

9.  If the rule incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material electronically, provide an explanation of why filing the text or other material electronically was infeasible:

n/a

10.  If the rule is being rescinded and incorporates a text or other material by reference, and it was infeasible for the agency to file the text or other material, provide an explanation of why filing the text or other material was infeasible:

Not Applicable.

11.  If revising or refiling this rule, identify changes made from the previously filed version of this rule; if none, please state so. If applicable, indicate each specific paragraph of the rule that has been modified:

The Bureau is revise filing this rule to clarify language in the fee schedule appendix of this rule regarding payment for services designated as "by report" and "not routinely covered."

12.  Five Year Review (FYR) Date: 2/1/2020

(If the rule is not exempt and you answered NO to question No. 1, provide the scheduled review date. If you answered YES to No. 1, the review date for this rule is the filing date.)

NOTE: If the rule is not exempt at the time of final filing, two dates are required: the current review date plus a date not to exceed 5 years from the effective date for Amended rules or a date not to exceed 5 years from the review date for No Change rules.

FISCAL ANALYSIS

13.  Estimate the total amount by which this proposed rule would increase / decrease either revenues / expenditures for the agency during the current biennium (in dollars): Explain the net impact of the proposed changes to the budget of your agency/department.

This will have no impact on revenues or expenditures. 0.00

The current recommendations will result in estimated total 2016 payments of

$121,162,832, which will be flat in comparison to 2015.

14.  Identify the appropriation (by line item etc.) that authorizes each expenditure necessitated by the proposed rule:

n/a

15.  Provide a summary of the estimated cost of compliance with the rule to all directly affected persons. When appropriate, please include the source for your information/estimated costs, e.g. industry, CFR, internal/agency:

The impacted business community consists of the hospitals that provide outpatient care to injured workers and self insured employers that also administer this rule.

Implementation of fee schedule changes is a necessary part of yearly methodology updates for both hospitals and self insuring employers. Because this methodology is largely based on Medicare, both hospitals and self insuring employers will realize

minimal adverse impacts. The adverse impact to the self insured employers will be employer time and/or reimbursement business expense for programming and executing the fee schedule changes. The adverse impact to hospitals will be the cost of hospitals to incorporate relevant changes into the hospitals' billing system.

16.  Does this rule have a fiscal effect on school districts, counties, townships, or municipal corporations? No

17.  Does this rule deal with environmental protection or contain a component dealing with environmental protection as defined in R. C. 121.39? No

S.B. 2 (129th General Assembly) Questions

18.  Has this rule been filed with the Common Sense Initiative Office pursuant to

R.C. 121.82? Yes

19.  Specific to this rule, answer the following:

A.) Does this rule require a license, permit, or any other prior authorization to engage in or operate a line of business? No

B.) Does this rule impose a criminal penalty, a civil penalty, or another sanction, or create a cause of action, for failure to comply with its terms? No

C.) Does this rule require specific expenditures or the report of information as a condition of compliance? Yes

To be paid, providers must submit fee bills for payment to the Bureau's Managed Care Organizations (MCOs).