176.1363 AMBULATORY SURGICAL CENTER PAYMENT.

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Subdivision 1.Definitions.

(a) For the purpose of this section, the terms defined in this subdivision have the meanings given them.

(b) “Ambulatory surgical center” or “ASC” means a facility that is: (1) certified as an ASC by the Centers for Medicare and Medicaid Services; or (2) licensed by the Department of Health as a freestanding outpatient surgical center and not owned by a hospital.

(c) “Ambulatory surgical center payment system” or “ASCPS” means the system developed by the Centers for Medicare and Medicaid Services for payment of surgical services provided by federally certified ASCs as specified in:

(1) Code of Federal Regulations, title 42, part 416, including without limitation the geographic adjustment for the ASC;

(2) annual revisions to Code of Federal Regulations, title 42, part 416, as published in the Federal Register;

(3) the corresponding addendum AA (final ASC covered surgical procedures), addendum BB (final covered ancillary services integral to covered surgical procedures), addendum DD1 (final ASC payment indicators), and any successor or replacement addenda; and

(4) the Medicare claims processing manual.

(d) “Conversion factor” means the Medicare ambulatory surgical center payment system (ASCPS) conversion factor used for ASCs that meet the Medicare quality reporting requirements, whether or not the ASC submitting the bill has met the quality reporting requirements.

(e) “Covered surgical procedures and ancillary services” means the procedures listed in ASCPS, addendum AA, and the ancillary services integral to covered surgical procedures listed in ASCPS, addendum BB.

(f) “Insurer” includes workers’ compensation insurers and self-insured employers.

(g) “Medicare ASCPS payment” means the Medicare ASCPS payment used for ASCs that meet the Medicare quality reporting requirements, whether or not the ASC submitting the bill has met the Medicare quality reporting requirements. §

Subd. 2.Payment for covered surgical procedures and ancillary services based on Medicare ASCPS.

(a) Except as provided in subdivision 3, the payment to the ASC for covered surgical procedures and ancillary services shall be the lesser of:

(1) the ASC’s total usual and customary charge for all services, supplies, and implantable devices provided; or

(2) the Medicare ASCPS payment on the total bill, times a multiplier of 320 percent.

(i) The amount payable under this clause includes payment for all implantable devices, even if the Medicare ASCPS would otherwise allow separate payment for the implantable device.

(ii) The 320 percent described in this clause must be adjusted if, on July 1, 2019, or any subsequent July 1, the conversion factor is less than 98 percent of the conversion factor in effect on the previous July 1. When this occurs, the multiplier must be 320 percent times 98 percent divided by the percentage that the current Medicare conversion factor bears to the Medicare conversion factor in effect on the prior July 1. In subsequent years, the multiplier is 320 percent, unless the Medicare ASCPS conversion factor declines by more than two percent.

(iii) When more than one covered surgical procedure is included on a bill, payment shall be: (A) 100 percent of the applicable ASCPS payment amount under paragraph (a), clause (2), for the procedure with the highest ASC payment rate; and (B) 50 percent of the applicable ASC payment amount under paragraph (a), clause (2), for all other covered surgical procedures. However, the total payment must still not exceed the ASC’s usual and customary charge for all services, supplies, and implantable devices provided. This item only applies when more than one procedure on a bill is identified as subject to multiple procedure discounting on Addendum AA.

(b) Payment under this section is effective for covered surgical procedures and ancillary services provided by an ASC on or after October 1, 2018, through September 30, 2019, and shall be based on the addenda AA, BB, and DD1 most recently available on the Centers for Medicare and Medicaid Services website as of July 1, 2018, and the corresponding rules and Medicare claims processing manual described in subdivision 1, paragraph (c).

(1) Payment for covered surgical procedures and ancillary services provided by an ASC on or after each subsequent October 1 shall be based on the addenda AA, BB, and DD1 most recently available on the Centers for Medicare and Medicaid Services website as of the preceding July 1 and the corresponding rules and Medicare claims processing manual.

(2) If the Centers for Medicare and Medicaid Services has not updated addendum AA, BB, or DD1 on its website since the commissioner’s previous notice under paragraph (c), the addenda identified in the notice published by the commissioner in paragraph (c) and the corresponding rules and Medicare claims processing manual shall remain in effect.

(3) Addenda AA, BB, and DD1 under this subdivision include successor or replacement addenda.

(c) The commissioner shall annually give notice in the State Register of any adjustment to the multiplier under paragraph (a), clause (2), and of the applicable addenda in paragraph (b) no later than October 1. The notice must identify and include a link to the applicable addenda. The notices and any adjustment to the multiplier are not rules subject to chapter 14, but have the force and effect of law as of the effective date published in the State Register. §

Subd. 3.Payment for compensable surgical services not covered under ASCPS.

(a) If a surgical procedure provided by an ASC is compensable under this chapter but is not listed in addendum AA or BB of the Medicare ASCPS, payment must be 75 percent of the ASC’s usual and customary charge for the procedure with the highest charge. Payment for each subsequent surgical procedure not listed in addendum AA or BB must be paid at 50 percent of the ASC’s usual and customary charge.

(b) Payment must be 75 percent of the ASC’s usual and customary charge for a surgical procedure or ancillary service if the procedure or service is listed in Medicare ASCPS addendum AA or BB and: (1) the payment indicator provides it is paid at a reasonable cost; or (2) the payment indicator provides it is contractor priced. §

Subd. 4.Study.

The commissioner shall conduct a study analyzing the impact of the reforms, including timeliness and accuracy of payment under this section, and recommend further changes if needed. The commissioner must report the results of the study to the Workers’ Compensation Advisory Council and the chairs and ranking minority members of the legislative committees with jurisdiction over workers’ compensation by January 15, 2021. §

Subd. 5.Rulemaking.

The commissioner may adopt or amend rules using the authority in section 14.386, paragraph (a), to implement this section and the Medicare ASCPS for workers’ compensation. The rules are not subject to expiration under section 14.386, paragraph (b).

History:

2018 c 185 art 4 s 1; 2021 c 12 s 5-7

History: History: 2018 c 185 art 4 s 1; 2021 c 12 s 5-7