CMS Finalizes the 2027 Outpatient Payment Rule: What Hospitals Should Model Now

CMS published the final 2027 Outpatient Prospective Payment System (OPPS) rule on November 6, and the headline number is not the one that matters.

The base update is a 2.3% increase to outpatient department payment rates. But two finalized policies pull the other way for many organizations:

340B drug payments fall from average sales price (ASP) plus 6% to ASP minus 28%. CMS softened its proposed cut of ASP minus 33.4%, and the reduction is budget-neutral: non-drug OPPS payments rise 7.5% to offset it. One more wrinkle: hospitals subject to the separate 340B remedy offset, generally those enrolled in Medicare before January 1, 2018, give back 2 percentage points of that adjustment, for a net 5.5% boost to non-drug payments. That 5.5% is one piece of the rule, not the total annual payment change; the 2.3% base update and the rule’s other provisions apply separately. Whether the trade works for you depends on your 340B volume and whether the remedy offset applies.

Site-neutral payment expands to imaging. Certain imaging without contrast – including some bone density scans, X-rays, ultrasounds, CT scans and MRIs – performed at off-campus hospital outpatient departments will be paid at the lower site-neutral rate.

Two hospitals with identical service lines can experience this rule very differently. The organizations that come out ahead will model their specific mix of 340B drugs, imaging volume and off-campus locations before January 1, and fix the charge-capture and coding issues the new rates expose.

That modeling is the work our revenue cycle teams do every day, on-site and inside our clients’ own systems. If you want a read on what the 2027 rule means for your numbers, talk to us.

Source: HFMA, “2027 Medicare OPPS final rule: Key payment shifts” – https://www.hfma.org/payment-reimbursement-and-managed-care/2027-medicare-opps-final-rule-340b-payments/