Centers for Medicare & Medicaid Services (CMS) is the federal agency that administers the Medicare program and is responsible for the policies within the Medicare PFS. However, CMS also must operate under the requirements set by Congress under the law.

OBFA and other aligned stakeholders are taking our message both to CMS and the Congress to advocate for permanent relief from the cuts that have been so devastating to office-based interventional care for years.

The Medicare Physician Fee Schedule (PFS) is one of several annual Medicare reimbursement regulations. In general, the PFS regulation reimburses physicians, therapists, and other practitioners for the care they provide to Medicare patients under the Traditional Fee-For-Service Medicare program.

It's important to note that while the HOPPS and ASC Fee Schedules include only technical payments (e.g., the high-technology equipment, supplies and other interventions that have been a hallmark of the U.S. healthcare system) for HOPDs and ASCS, the PFS includes technical payments for office-based providers plus professional payments for physicians in all settings (e.g. HOPD, ASC and office). As a result, PFS technical payments currently “budget-neutralize” office-based supplies and equipment to dissimilar items such as professional payments for physician work in the hospital.

These non-sensical reimbursement streams are one of many reasons why the so-called PFS budget-neutrality provision is a significant concern. When the PFS “budget-neutralizes” it does not do so for all professional and technical services in the PFS, HOPPS, and ASC settings. Rather, the PFS only budget-neutralizes for physician work and office-based technical resources, while leaving HOPPS and ASC reimbursement outside of PFS budget-neutrality effects. This dynamic contributes to the significant payment volatility within the PFS.

Included in PFS Budget Neutrality

• Office Technical Component

• Office Professional Component

• Hospital Professional Component

• ASC Professional Component

Not Included in PFS Budget Neutrality

• Hospital Technical Component

• ASC Technical Component

Rationalizing ambulatory payment systems could involve ambulatory (HOPD/ASC/Office) technical payments being paid within a single ambulatory technical fee schedule outside of the PFS and reserving the PFS strictly for reimbursement of professional payments.

There are actually two regulations to keep on your radar. The first is the “proposed” PFS regulation, which is usually issued in the summer and proposes regulations for the following calendar year. The “final” PFS regulation is usually issued on or around November 1.