2027 OPPS: The 5 Provisions Health Systems Should Be Evaluating

CMS published its 2027 Outpatient Prospective Payment System proposed rule last month. At a moment when health systems across the country are signing letters of intent, closing acquisitions and negotiating capital commitments, this rule introduces five provisions that will reshape the financial math behind those decisions. Comments are due August 31.

1. The 340B drug payment cut is back, and it is bigger than before.

When the Supreme Court struck down CMS's earlier 340B payment reduction in American Hospital Association v. Becerra, the agency was told it lacked the acquisition-cost survey required to justify the cut. CMS has now conducted that survey. The proposal: reduce 340B drug reimbursement from ASP plus 6% to ASP minus 33.4%. That is a 37% reduction in per-drug Medicare revenue for every non-exempt 340B hospital. For large systems with robust 340B programs, this is not a rounding error. It is tens to hundreds of millions of dollars annually. CMS also has put forward an alternative rate of ASP minus 28%, which gives stakeholders a specific number to push back toward in comments. Children's hospitals, PPS-exempt cancer hospitals, and sole community hospitals are exempt. Disproportionate share hospitals are not.

2. The 340B budget neutrality recoupment is accelerating.

Separate from the drug rate cut, CMS is proposing to triple the annual recoupment rate for the $7.8 billion in non-drug payments that flowed to all OPPS hospitals during the 2018-2022 period when the unlawful payment reduction was in effect. The rate increases from 0.5% to 3% annually, with full recoupment projected by 2029. In the 2026 rule, CMS proposed 2% and backed down after hospital opposition. It said at the time that hospitals should expect a higher rate in 2027. It delivered. Health systems that built financial projections around the 16-year glide path established in 2023 are now looking at a three-year runway instead. These two 340B provisions do not operate independently. They stack.

3.Provider-based attestations now require formal verification, and the clock is ticking.

Off-campus hospital outpatient departments must submit a standardized Provider-Based Attestation for each location by January 1, 2028. This is not a paperwork exercise. CMS is implementing a multi-phase review process that includes automated validation, targeted document review, site visits, and remote audits. The agency has made clear that the era of minimal oversight of provider-based status is over. For health systems that have grown through acquisition, particularly those that have added outpatient locations in recent years, this provision requires an immediate inventory of every off-campus department and an assessment of compliance with provider-based rules. A denied attestation means losing OPPS payment rates for that location.

4. Site-neutral payments are expanding to non-contrast imaging.

CMS proposes to apply site-neutral payment rates to non-contrast imaging services furnished at excepted off-campus hospital outpatient departments. The proposed reduction is approximately 60% from current OPPS rates, down to the comparable Physician Fee Schedule rate. CMS estimates $7.2 billion in Medicare savings over 10 years.

CMS has used this authority before for clinic visits and drug administration. Each time, it established a foothold and then expanded it. Non-contrast imaging is next. Health systems that rely on off-campus imaging revenue should model the impact now and consider whether submitting comments is warranted.

5. EMTALA compliance reviews are moving into routine accreditation surveys.

Currently, EMTALA compliance is reviewed only in response to a complaint. This rule changes that. Accrediting organizations, including the Joint Commission and DNV, would be required to incorporate EMTALA administrative requirements into standard accreditation surveys, with deficiencies addressed through established corrective action procedures. The practical effect: EMTALA compliance will be reviewed on a regular cycle rather than only when something goes wrong. Hospitals that have not recently audited their EMTALA administrative practices, including on-call lists, transfer records, and patient signage requirements, should do so before their next accreditation survey.

Why This Matters Now

The August 31 comment deadline falls in the middle of a period when many health systems are actively negotiating transactions, capital commitments, and long-term strategic decisions. These five provisions affect the financial projections underlying all of those decisions. Health systems in active acquisition conversations should be stress-testing deal models against both the proposed ASP minus 33.4% rate and the alternative ASP minus 28%. Boards approving capital commitments should understand that the 340B recoupment acceleration significantly shortens the planning horizon that was in place six months ago. Any system operating a significant number of off-campus outpatient departments should treat the PBA requirement as a compliance project that starts now, not in 2027.

The same modeling requirement applies to private equity sponsors and their portfolio companies in the hospital and health system space. Deal structures and return assumptions built on current reimbursement levels need to be revisited against this proposed rule before it finalizes.