Effective January 1, 2028, Medicare’s outpatient prospective payment system (OPPS) will not reimburse services furnished by an off‑campus hospital outpatient department unless that department meets specific guidelines as outlined in the Consolidated Appropriations Act (CAA) [1], Section 6225 as follows:
The department has submitted paperwork to Medicare, Medicaid and other payers to bill under its own location specific national provider identifier (NPI) that is separate from the hospital’s NPI, and
The hospital has submitted an initial provider‑based attestation demonstrating compliance with 42 C.F.R. § 413.65 [2] between January 1, 2026 and December 31, 2027 for each off-campus outpatient department that is held out as a provider-based department of the hospital.
It is important to note that if an initial attestation is not submitted by January 1, 2028, Medicare payments for hospital services furnished at the off-campus department may cease. Importantly, the attestation is no longer voluntary nor a one-time submission, meaning hospitals will be required to submit subsequent provider-based attestations for each off-campus outpatient department on a periodic basis.Finally, the new requirements apply to all off‑campus departments paid under OPPS, including sites previously “excepted” or grandfathered.
Due to the impending changes, it’s important to assess each of your facility’s compliance with the provider-based rules and address any identified issues proactively. Based on the results of the assessment, some organizations may need to restructure off-campus departments as a different provider type to preserve Medicare reimbursement, which could affect the existing off-campus department 340B eligibility and potentially reduce organizational revenue. Additionally, if required attestations are not filed for off-campus department’s, the site may lose eligibility for 340B reimbursement.
Additional guidance on these requirements will be provided as CMS develops new regulations in the following areas:
Submission and review procedures for provider-based attestations.
Timelines for hospitals to submit subsequent attestations.
Compliance review procedures for CMS to verify provider compliance with the requirements.
Given the complexity of these requirements, we recommend hospitals take a proactive approach to ensure compliance with the new requirements and maintain a clear oversight of all hospital off-campus outpatient departments. Actionable steps include:
Create a complete inventory, for all on-campus versus off-campus provider-based facilities, along with the associated NPI’s.
Evaluate each facility’s compliance with the provider-based requirements. We recommend reviewing copies of bills generated for the off-campus locations to ensure the correct NPI is contained within the billing platform.
Create attestations for each off-campus provider-based facility in compliance with 42 C.F.R §413.65.
Develop a strategy for obtaining NPI’s and associated impact to the 340B program eligibility.
Create a system to track the submissions to Medicare.
Maintain documentation to support provider-based status in the event of a CMS audit.
Timely implementation of these requirements is essential to protect hospital reimbursement, as well as ongoing reviews of hospital off-campus department regulations to maintain compliance and preserve reimbursement.
SunStone is uniquely qualified to assist providers navigate the new environment due to our extensive experience assisting providers in achieving compliance with provider-based requirements. Should you have any questions, please contact Vonda Moon, Senior Principal, at vondamoon@sunstoneconsulting.com, Kristie Bailey, Director Revenue Cycle Management at kristiebailey@sunstoneconsulting.com or Adrienne Sowers, Director Revenue Cycle Management at adriennesowers@sunstoneconsulting.com.