Medicare currently pays two to four times more for an X-ray or CT scan without contrast when the machine sits inside a hospital's outpatient department instead of a doctor's office across the street, even when the same radiologist reads both films. On July 2, CMS proposed ending that gap.
The CY2027 Hospital Outpatient Prospective Payment System rule would extend site-neutral payment to imaging without contrast furnished in off-campus hospital outpatient departments, pushing reimbursement toward the physician-fee-schedule rate regardless of which building holds the scanner. The comment period runs through August 31. Here is what actually changes, and the three numbers your finance team should already be running.
Site-neutral payment is not a new idea. CMS has chipped at the site-of-service gap since the 2019 clinic-visit policy, and the fight over off-campus provider-based billing has run for most of a decade. What is new in the CY2027 proposal is the category: imaging without contrast, a high-volume, low-complexity service line that many hospital systems have quietly relied on to cross-subsidize lower-margin care.
The mechanics:
A radiologist reading a chest X-ray does not read it differently depending on which building it was taken in. The image resolution does not change. The interpretation time does not change. What changes is a billing modifier tied to real estate: a hospital-owned, off-campus imaging center bills as a hospital outpatient department, and Medicare pays the OPPS rate built for a higher-acuity setting the imaging itself never actually uses.
"That gap financed something. Closing it does not make the subsidized care cheaper to deliver. It removes the line item that was quietly paying for it."
Hospitals have used the margin on high-volume, low-complexity imaging to subsidize emergency departments, trauma coverage, and other service lines that lose money on their own. Closing the gap does not make that subsidized care cheaper to deliver. It removes the line item that was quietly paying for it.
Three questions belong on a CFO's desk this month, not after the rule finalizes.
Imaging without contrast is one category. It will not be the last. CMS has signaled for years that site-neutral payment is a direction, not a one-time policy, and every high-volume, low-complexity service line billed at a hospital rate for reasons that have nothing to do with clinical complexity is a future candidate. The systems that model their exposure now, rather than after the next proposed rule lands, get to plan the transition instead of absorbing it.
The comment period is open. The modeling should already be done.
Surgery-trained, currently practicing internal medicine (charity care). If you are on a board or finance team trying to get ahead of the next site-neutral category before it becomes a budget crisis, that is the work I do.
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