ADVOCACY SPOTLIGHT This website is a great resource
for individuals and families because it clearly shows the savings that ASCs provide to both Medicare’s benefi- ciaries and the Medicare program. It also has illustrated a long-standing payment discrepancy between ASCs and HOPDs. For example, after years of ASCA’s advocacy during the rule- making process, the Centers for Medi- care & Medicaid Services (CMS) moved code 27447, which indicates a total knee arthroplasty, onto the ASC- payable list. In an ASC, the total cost for this procedure would be about $8,609, with the beneficiary facing a $1,721 copay and Medicare reimbursing $6,887. In the HOPD, the total cost for this procedure would be about $11,900, with the beneficiary facing
a $1,408 copay and Medicare reim- bursing $10,492. In this instance, a beneficiary’s copay is higher in the ASC than in the HOPD, with the ben- eficiary facing a $313 penalty for receiving care in an ASC and the cost to Medicare about $3,290 higher. This penalty occurs because a ben-
eficiary’s copay is capped when they receive care in an HOPD. For code 27447, and all codes that have a total cost greater than or equal to $7,040, a beneficiary’s copay for HOPD ser- vices is capped at $1,408, which is the deductible amount for inpatient care under Medicare Part A. Congress extended the Part A deductible for inpatient services to outpatient HOPD services under Part B in legislation that was signed into law in 1999. That law also made
HOPDs whole for the difference in the capped copay and what other- wise would have been the beneficia- ry’s coinsurance responsibility. This change was made to protect ben- eficiaries and increase access to the more efficient side of the hospital. When Congress directed HHS to
revise the ASC reimbursement sys- tem in 2003, however, the language of that bill did not include a provi- sion similar to the 1999 law that capped HOPD copayments, which has resulted in a difference in pay- ments. This copay cap issue impacts 134 codes on the ASC payable list, which is about 4 percent of the codes payable under Medicare.
This raises a host of issues. First and foremost, beneficiaries are pena- lized by a higher copay if they choose
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