In April 2009, the BWC again turned to CMS for a methodology to reimburse the ASC, whose fee schedule had not been updated since 2005. CMS publishes an Ambulatory Surgical Center Prospective Payment System (ASC PPS). BWC has adopted the published 2010 ASC PPS payment rate and reimburses 100 percent of the CMS rate, moving from the old ASC Group methodology.
- In developing the vocational rehabilitation provider fee schedule, the BWC could not turn to CMS for a methodology as the codes and reimbursement for these services are not part of the Medicare population. There are 77 codes that make up the vocational rehabilitation fee schedule, and each of these codes was reviewed using data from other workers’ compensation systems that provide vocational rehabilitation as part of their benefit plan. In 50 of the 77 codes, fee increases were recommended.
- The final fee schedule to undergo a complete revision is the Outpatient Hospital fee schedule. The current reimbursement is a retrospective cost-plus ratio not to exceed 60 percent of billed charges, utilizing Ohio Medicare’s cost to charge ratios (CCR), which made estimating the cost of these services difficult, if not impossible.
The proposed fee schedule is to adopt a modified version of Medicare’s Outpatient Prospective Payment System (OPPS) and move from the retrospective cost-plus methodology. OPPS uses Ambulatory Payment Classifications (APCs) assigned to each CPT/HCPCS code, with a set predetermined payment amount. APCs are groups of clinically similar procedures or services with similar resource consumption.
OPPS also partially packages services so services, supplies and procedures are built into the reimbursement rate. BWC will use the OPPS rates times the BWC established payment adjustment factor, similar to the conversion rate in inpatient reimbursement, to set the modified OPPS reimbursement rate.
Why should employers care about these fee schedule changes?
The BWC has undertaken a huge revision of the process of setting fee schedules, moving from a retrospective payment methodology to a prospective payment methodology, which will promote equity and consistency on payments, encourage improved efficiencies of providing care and allow for some predictability of payments. To do this, they turned to the CMS, a branch of the government that provides the vast research and review necessary for all the different areas and types of fee schedules.
In addition, following the lawsuit by the Ohio Hospital Association, BWC is required to make changes to any fee schedule via the rulemaking process. This requires all fee schedules to be presented and approved by the BWC Board of Directors through a two-step reading process.
