Sponsors
Last progress April 24, 2025 (10 months ago)
Introduced on April 24, 2025 by Victoria Spartz
Requires off-campus hospital outpatient departments to bill using their own unique National Provider Identifier (NPI) and prevents those locations from being billed as if they were on-campus hospital sites. Updates Medicare and commercial claims rules to require the department-level NPI on standard claim forms, and asks the National Association of Insurance Commissioners (NAIC) to draft a model state law to help enforce the commercial billing changes; most provisions take effect for services furnished on or after 2026-01-01.
Amends the Social Security Act definition of “off-campus outpatient department of a provider” (section 1833(t)(21)(B)) to remove certain exceptions so the term covers departments not on the provider’s campus or within the campus distance definition.
Amends section 1833(t)(21)(A) of the Social Security Act to remove the site-neutral exception for off-campus emergency departments.
Adds a sentence to section 1833(t)(2)(F) clarifying that the Secretary of Health and Human Services may take actions to promote site-neutral payment policies, including actions to prevent hospitals from billing for items and services furnished at an off-campus outpatient department as if furnished at the hospital.
Adds a new paragraph to section 1173(b) of the Social Security Act requiring that each off-campus outpatient department of a provider be assigned a separate unique health identifier (NPI) from the parent provider, to be ensured by standards not later than January 1, 2026.
Directs the Secretary of Health and Human Services to revise 45 C.F.R. §§162.408 and 162.410 by January 1, 2026 so that each off-campus outpatient department is treated as a subpart of the provider and is assigned a unique health identifier pursuant to the new paragraph in section 1173(b).
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Who is affected and how:
Hospitals and hospital outpatient departments: Must obtain and use separate NPIs for each off-campus outpatient department and update billing, scheduling, and EHR systems. Departments previously billed under the main hospital NPI may see changes in how payers classify and reimburse those services, potentially reducing facility fees where site-of-service distinctions change.
Health care providers and billing offices: Increased administrative work to register department-level NPIs, change claim-submission workflows, and ensure correct NPI usage on standard claim forms. Smaller providers affiliated with hospitals may need technical assistance to comply.
Medicare beneficiaries and privately insured patients: May see changes in how services are billed and reimbursed, which can change patient cost-sharing (copays, coinsurance) depending on payer rules for off-campus vs on-campus sites.
Medicare and commercial payers / health insurance issuers: Must adapt claims-processing systems to require and accept the specific department NPIs and potentially revise payment logic tied to site of service. Insurers will need to coordinate with providers and possibly state regulators to enforce proper billing.
State insurance regulators and NAIC: The NAIC is asked to produce a model law to help states enforce the commercial billing requirements; states that adopt such a model may create uniform enforcement but adoption is discretionary. This could create variation across states depending on whether they adopt the model.
Net effects: The rule increases billing transparency and aims to reduce misclassification of off-campus outpatient departments as on-campus facilities. That transparency may lower certain facility fee payments and shift revenue for some hospital departments, while imposing upfront administrative and IT costs on providers and payers. Because the NAIC model and state adoption drive enforcement for commercial plans, enforcement and impact on commercially insured patients may vary by state.