CMS raising rate for outpatient lung cancer screening by more than 37% in final rule

The Centers for Medicare & Medicaid Services is raising the reimbursement rate for hospital outpatient lung cancer screening by more than one-third according to a final rule released Nov. 2.

Payment for low-dose CT scans in this setting would leap from about $80.90 to $111.19 in 2022, a 37.44% uptick. The change is part of a nearly 1,400-page Medicare Hospital Outpatient Prospective Payment System final rule, detailing numerous changes impacting the specialty.

Radiology advocates praised the pay update late Tuesday.

“The [American College of Radiology] has raised concerns about the inadequate payments for CT lung screening based on flawed hospital data for several years,” the professional association said in its own summary of the HOPPS announcement. “As a result of these comments, the ACR is very pleased that CMS has reassigned [current procedural terminology] code 71271 to the second tier Imaging without Contrast [Ambulatory Payment Classification] (5522) …”

CMS said one of its chief concerns is addressing price transparency among outpatient hospital settings. The agency recently began requiring institutions to provide upfront pricing for care, including 13 “shoppable” radiology services  specified by the feds. However, recent analyses have discovered many hospitals failing to honor the requirements.

To address this, CMS is increasing the penalty for those that do not comply. Smaller hospitals (30 beds or fewer) would face a minimum monetary penalty of $300 per day, while larger institutions above that threshold will pay $10 per bed per day. This would result in a minimum total penalty of $109,500 for a full year of noncompliance and max of more than $2 million. The American Hospital Association said Tuesday that it supports price transparency but is “very concerned” about the significant penalty increases.

“CMS is committed to promoting and driving price transparency, and we take seriously concerns we have heard from consumers that hospitals are not making clear, accessible pricing information available online, as they have been required to do since January 1, 2021,” CMS Administrator Chiquita Brooks-LaSure said in a statement.

Following numerous delays, the outpatient rule also plans to kick off the Radiation Oncology Model on Jan. 1, 2022. The program aims to create more predictable payments in cancer care, incentivize the use of less costly treatment, and save $230 million over the next five years. CMS will do so by providing bundled payments during a 90-day episode of care to radiotherapy providers treating one of 16 different cancer types. It will require participation from physicians in randomly selected geographic areas that contain about 30% of all eligible Medicare fee-for-service radiotherapy episodes nationally.

The American Society for Radiation Oncology on Tuesday called the planned start date “extremely challenging.”

“While we appreciate some new flexibilities to account for the public health emergency, payment cuts are the last thing practices need as they continue to weather the pandemic and care for growing numbers of patients with advanced-stage cancers due to pandemic-related cancer screening delays,” Laura Dawson, MD, chair of ASTRO’s Board of Directors, said in a statement. “We will continue to engage with CMS on ways to improve quality without forcing onerous reporting requirements.”

For more on the final rule, you can read the American College of Radiology’s summary, this CMS fact sheet, or the full document, slated to be published in the Federal Register Nov. 16.

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