Preventing Hospital Overbilling of Medicare Act
Sponsored By: Representative Spartz
Introduced
Summary
Site-neutral payments are the bill’s main goal. It would stop hospitals from using exceptions to bill off-campus outpatient departments at higher hospital rates and require separate identifiers and billing formats for those departments.
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- Hospitals and providers: Would remove exceptions that let some off-campus outpatient departments be paid like on-campus hospital sites for Medicare, with the change applying to services furnished on or after January 1, 2026.
- Medicare program and beneficiaries: Would push Medicare toward broader site-neutral payments for off-campus departments to reduce expenditures and prevent hospitals from billing at hospital rates.
- Off-campus outpatient departments: Would have to use a separate national provider identifier (NPI) by January 1, 2026 and bill using HIPAA X12 837P transactions or CMS 1500 forms for services on or after that date.
- Health plans and state regulators: Creates a new section that bars group health plans and issuers from paying claims for an off-campus department unless they use the department’s separate NPI and specified claim forms, and directs the National Association of Insurance Commissioners (NAIC) to adopt a model law within six months to enforce this.
*Would aim to lower federal Medicare spending by expanding site-neutral payments for off-campus outpatient departments starting in 2026.*
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Bill Overview
Analyzed Economic Effects
2 provisions identified: 1 benefits, 0 costs, 1 mixed.
Medicare payment changes for off-campus care
This bill would change how Medicare treats care at hospital locations that are not on the main campus. Starting January 1, 2026, more sites could be classified as off‑campus departments under a tighter definition. The special site‑neutral rule for off‑campus emergency rooms would only apply to care before January 1, 2026; care on or after that date could see higher payments and higher patient cost‑sharing. HHS would also get more power to promote site‑neutral payments and stop hospitals from billing off‑campus care as if it happened at the main hospital, aiming to reduce Part B spending.
New billing IDs for off-campus hospital care
If enacted, off-campus hospital departments would need their own unique ID by January 1, 2026. Medicare, including Medicare Advantage, and private plan claims for care at these sites would have to use that ID and be sent on the HIPAA X12 837P or CMS 1500 form (or a successor). Providers would not be able to bill your plan or make you pay for care on or after January 1, 2026, unless they follow these rules. HHS would also ask states, within six months, to adopt a model law so plans can reject non‑compliant claims.
Sponsors & CoSponsors
Sponsor
Spartz
IN • R
Cosponsors
There are no cosponsors for this bill.
Roll Call Votes
No roll call votes available for this bill.
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