CMS’s CY 2027 OPPS proposed rule would implement Section 6225 of the Consolidated Appropriations Act, 2026: every off-campus hospital outpatient department needs its own NPI and a filed provider-based attestation, or Medicare payment is unavailable for services furnished by that department beginning January 1, 2028. The same rule proposes moving imaging without contrast to physician-office rates in excepted off-campus departments — the third service family in three years. The compliance project and the erosion of what it protects are running on the same clock.
The comment window on the CY 2027 OPPS/ASC proposed rule, CMS-1850-P, closed August 31, 2026. The finance question stops being what to write and becomes what to model.
Two provisions in that rule move in opposite directions, and hospital finance teams are being asked to fund both at once.
CMS has proposed regulations implementing Section 6225 of the Consolidated Appropriations Act, 2026. The mechanism is administrative and the consequence is not. Beginning January 1, 2028, Medicare payment is unavailable for services furnished by an off-campus provider-based department unless that department satisfies two requirements: it has obtained and bills under its own unique NPI, separate from the hospital’s, and the hospital has filed a provider-based attestation demonstrating compliance with 42 CFR § 413.65 in the prescribed window. The payment consequence applies under OPPS and, where applicable, under the site-neutral payment methodology for non-excepted departments.
Section 6225 is not itself a site-neutral rate methodology. It is a condition of Medicare payment that applies to off-campus provider-based departments whether they are paid under OPPS or, where applicable, a site-neutral payment method.
For a department that needs payment eligibility on January 1, 2028, the practical initial-attestation period runs from January 1, 2026 through December 31, 2027. The proposed requirement turns on submission, not CMS completion of its review. For departments established later, the proposed policy uses a rolling two-year period: the initial attestation must be submitted within the two-year period preceding the date services are furnished. CMS also proposes subsequent attestation requirements at intervals it will establish, no less frequently than once every five years.
Note what this is not. It is not a rate cut and it does not turn on whether the department is excepted or non-excepted under Section 603 of the Bipartisan Budget Act of 2015. It is a filing requirement whose penalty for non-performance is that a revenue-producing location stops being payable. A department that has operated for a decade under an attestation the hospital filed in 2014 and never thought about again is exposed on the same terms as one opened last year.
For a system with fifteen or forty off-campus departments, the exposure is not conceptual. It is the sum of Medicare payment at every site where somebody cannot currently produce the attestation file, multiplied by the probability that the site’s NPI enrollment work does not get done inside fifteen months of a Medicare enrollment queue you do not control. The correct treasury framing is that this is a documentation project with a revenue-recognition consequence, and the two functions that have to execute it — provider enrollment and regulatory compliance — are usually not the ones with visibility into what each site bills.
Now the other direction.
The value of provider-based status at an off-campus department is the OPPS payment differential over the Physician Fee Schedule rate for the same service. CMS has been narrowing that differential on a service-family cadence since 2019, using its authority under section 1833(t)(2)(F) of the Social Security Act to control unnecessary volume increases.
The sequence is worth laying out because it reads as a policy trajectory rather than a series of one-offs. In the CY 2019 OPPS final rule, CMS applied the PFS-equivalent rate to clinic visit services furnished in excepted off-campus provider-based departments. In the CY 2026 final rule, it extended that method to drug administration services. For CY 2027, CMS proposes to extend it again, to imaging without contrast — applying the PFS-equivalent rate to the identified imaging-without-contrast services in the addenda when furnished at an excepted off-campus PBD, with rural sole community hospitals exempted.
CMS estimates the imaging provision alone would reduce Medicare Part B expenditures by approximately $260 million in the first year — roughly $190 million in Part B savings and $70 million in reduced beneficiary premiums, with beneficiary cost sharing down another $70 million.
Three service families in three rulemaking cycles, each of them a high-volume ambulatory category, each one taken from the same population of departments that were supposed to be permanently protected by having been grandfathered in 2015. The word “excepted” is doing less work every year.
So the modeling exercise for 2028 has two independent variables, not one. The first is whether a given off-campus department clears the Section 6225 requirements at all. The second is what an OPPS-paid department is still worth once clinic visits, drug administration, and imaging without contrast are all paying at physician-office rates. For a site whose volume is concentrated in those three families, the honest answer may be that the differential no longer justifies the compliance overhead — which is a conversion decision, and conversion decisions take longer than fifteen months.
The same rule carries three other items that belong in the same model, and they do not net out cleanly.
CMS proposes an OPPS update of 2.4% for hospitals meeting quality reporting requirements — a 3.2% projected market basket less a 0.8 percentage point productivity adjustment. It proposes to pay for 340B-acquired drugs at ASP minus 33.4%, following the January–April 2026 acquisition cost survey, estimated to cut Original Medicare drug payment by $4.55 billion and beneficiary drug payments by $1.15 billion in the first year, offset in a budget-neutral manner by an equivalent increase to non-drug payments — a positive non-drug rate adjustment of approximately 8.44%. And it proposes to raise the 340B remedy offset on the non-drug conversion factor from 0.5% to 3%, shortening the recovery of the $7.8 billion to a projected completion in CY 2029, excluding hospitals that enrolled in Medicare after January 1, 2018.
The hospital-specific result depends on the interaction of the drug-payment reduction, the positive budget-neutrality adjustment to non-drug OPPS rates, the separate remedy-recovery reduction for applicable hospitals, and the hospital’s own drug versus non-drug outpatient mix. The aggregate update factor cannot answer that question. A hospital with heavy 340B drug volume and light non-drug outpatient volume takes the ASP cut without collecting much of the offsetting non-drug increase. A non-340B hospital with high non-drug outpatient volume is on the other side of that ledger. The aggregate OPPS figure — approximately $110.9 billion in estimated CY 2027 payments, up roughly $9.5 billion — tells you nothing about where your own facility lands.
CMS also proposes removing 638 services from the Inpatient Only list in the second year of a three-year phase-out. That change may expand the circumstances in which selected procedures are furnished and paid outpatient, but it does not require outpatient treatment. Its financial relevance should be modeled separately from the limited site-neutral policies affecting clinic visits, drug administration, and specified imaging-without-contrast services.
CMS is expected to issue the final rule later in 2026, with policies generally effective January 1, 2027 if finalized. The Section 6225 requirements begin January 1, 2028, regardless of the CY 2027 OPPS rule’s ordinary effective date.
The modeling that is worth doing between now and then is not a sensitivity analysis on the conversion factor.
It is an inventory: every off-campus department, its NPI status, its attestation status, its share of revenue in clinic visits, drug administration, and imaging without contrast, and its 340B drug mix. Sites that fail on the first two columns are a compliance sprint. Sites that pass on the first two columns but are concentrated in the last three are a strategy question that the attestation deadline does not resolve.
If the imaging provision finalizes as proposed, which of your off-campus departments still earns its provider-based designation — and do you have fifteen months of runway to act on the answer?
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