Approaches for PPE Payment
In the “Ensuring Safety Through Domestic Security With Made in America Personal Protective Equipment (PPE) and Essential Medicine Procurement by Medicare Participating Hospitals” advance notice of proposed rulemaking (CMS-1516-ANPRM, 91 FR 3851 through 3856) issued earlier this year, CMS previously sought public comment on potential options we could consider for Medicare-participating hospitals to help foster a more resilient supply chain for American-made PPE and essential medicines “to secure our nation’s health and safety” and to reflect the additional resource costs incurred when procuring these domestically manufactured items. CMS is seeking further public input on this issue after reviewing the comments on that ANPRM to inform future rulemaking.
Hospital Outpatient Quality Reporting Program
The Hospital Outpatient Quality Reporting (OQR) Program is a pay-for-reporting program that requires hospital outpatient departments (HOPDs) to report data on certain quality measures specified by CMS. HOPDs that fail to submit the required quality data receive a 2-percentage point reduction to their annual payment update under the OPPS. CMS also makes data submitted by HOPDs for the Hospital OQR Program available to the public on Care Compare to inform quality improvement efforts and beneficiary decision-making.
In addition to the proposed cross-program measure removal described below, CMS is proposing updates to validation and validation appeals procedures to increase data accountability for digital quality measures. CMS is also requesting information on potentially including an Advance Care Planning measure for the hospital outpatient department setting.
ASC Quality Reporting Program
The ASC Quality Reporting Program is a pay-for-reporting program that requires freestanding ASCs to report data on specified measures of clinical quality. Under this program, eligible ASCs must meet all program requirements or may receive a 2-percentage point reduction to their annual payment rate update under the ASC fee schedule.
In addition to the proposed cross-program measure removal described below, CMS is soliciting information on potentially stratifying the All-Cause Transfer/Admission measure by phase of care.
Cross-Program Proposal
CMS is proposing to remove the Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients measure from the Hospital Outpatient and ASC Quality Reporting Programs, beginning with the CY 2027 reporting period/CY 2029 payment determination. This measure assesses whether the recommended 10-year interval for a follow-up colonoscopy is documented in the colonoscopy report. There is another colonoscopy measure in both programs tied more closely to clinical outcomes instead of documentation.
AO Deeming Authority for EMTALA
The Emergency Medical Treatment and Labor Act (EMTALA) requires all Medicare-participating hospitals, including Critical Access Hospitals (CAHs) and Rural Emergency Hospitals (REHs), to provide appropriate medical screening examinations, necessary stabilizing treatment to individuals with emergency medical conditions, as well as appropriate transfers for individuals presenting to emergency departments. CMS proposes to permit hospital Accrediting Organizations (AOs) with deeming authority to assess compliance with EMTALA's administrative requirements under 42 CFR 489.20, including posting required signage, maintaining a central emergency department log, retaining transfer records for five years, and keeping an on-call physician list as part of routine accreditation and reaccreditation surveys.
To implement this change, CMS would amend 42 CFR 488.5(a) by adding a new provision requiring AOs to document the procedures used to inspect for EMTALA administrative violations within their existing survey processes. Because more than 80% of hospitals are AO-accredited, integrating this oversight into routine surveys would reduce duplicative state complaint investigations and minimize disruption to hospital operations. Enforcement authority over the substantive patient care protections at 42 CFR 489.24 would remain exclusively with CMS and the Office of Inspector General (OIG). This enforcement authority includes EMTALA complaint investigations conducted by CMS, which are carried out to ensure compliance with the patient care protections set forth under 42 CFR 489.24.
Botulinum Toxin Injection Codes
Through routine data analysis, CMS identified that botulinum toxin injection procedures showed an increase in volume. Both data and research showed that an increase in volume for these procedures is unnecessary, and further program integrity action was warranted. In the 2020 OPPS final rule, CMS established a prior authorization process for certain hospital outpatient department (OPD) services using our authority under section 1833(t)(2)(F) of the Act, which requires the secretary of the U.S. Health and Human Services Department to develop “a method for controlling unnecessary increases in the volume of covered OPD services.”
CMS continues using prior authorization to reduce unnecessary increases in the volume of OPD services. In the 2027 OPPS proposed rule, CMS is proposing to require prior authorization for eight additional botulinum toxin injection codes. “CMS believes prior authorization is an effective mechanism to ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume and improper payments.”
To view the proposed rule, please click this link: https://www.federalregister.gov/d/2026-13656.