CMS Proposes Significant Changes in Medicare Outpatient Payment Structures for 2027
The Centers for Medicare and Medicaid Services (CMS) recently unveiled a proposed rule aimed at overhauling payment structures for hospital outpatient departments and ambulatory surgical centers under Medicare for the 2027 calendar year. Comments on this proposed rule are expected by August 31, 2026, as CMS seeks stakeholder input.
Provider-Based Department Compliance Attestations
As part of the reforms introduced by the Consolidated Appropriations Act of 2026, CMS plans to require hospital outpatient departments to complete a standardized compliance attestation form. This form, to be signed by an authorized official listed in the Provider Enrollment, Chain, and Ownership System (PECOS), aims to streamline the oversight process, anticipating a surge in attestation submissions.
Modifying 340B Drug Payments
CMS proposes altering payments for drugs within the 340B Drug Pricing Program to reflect the average sales price minus 33.4%, a departure from the previous ASP minus 22.5% rate overturned by the Supreme Court. The agency contends that these adjustments rectify prior statutory misinterpretations, ensuring more accurate reimbursement.
Imaging Services and Botulinum Toxin Procedures
The agency also suggests standardizing payment rates for imaging services without contrast between physician offices and off-campus provider-based departments. Moreover, CMS aims to implement prior authorization for eight additional botulinum toxin injection codes due to rising claims, enhancing medical necessity verification.
Price Transparency and Accreditation Updates
In an effort to amplify hospital price transparency, CMS calls for feedback on standardizing machine-readable files, especially concerning contract mechanisms like outlier payments and rate tiering. Additionally, amendments to quality reporting for Intensive Outpatient and Partial Hospitalization Programs are on the table, alongside provisions for accrediting bodies to evaluate compliance with certain Emergency Medical Treatment and Labor Act requirements.
The proposed changes in the CY 2027 OPPS rule represent a pivotal moment for outpatient services. Hospitals and other stakeholders are urged to evaluate the proposal in detail and provide their insights before the deadline. Morgan Lewis & Bockius LLP will furnish a deeper analysis, particularly on aspects concerning PBD attestations and 340B drug reimbursement adjustments.