H.R. 7863: Promoting Fairness for Medicare Providers Act of 2026

This bill, known as the Promoting Fairness for Medicare Providers Act of 2026, aims to modify how Medicare pays for certain surgical procedures performed in office-based facilities. The key components of the bill include:

1. Coverage of Facility Services

Starting in 2027, Medicare will cover specific surgical procedures performed in office-based facilities that have high supply costs. The bill specifies a definition for these high-cost surgical procedures, highlighting their relevance in billing and coverage considerations.

2. Payment Rules

The bill establishes new payment rules for facility services related to high supply cost surgical procedures. Key changes include:

• Medicare will pay 80% of certain amounts determined for facility services associated with these procedures performed in an office-based facility.
• The payment calculation will align more closely with the rates set for ambulatory surgical centers, recognizing that these procedures often incur significant supply costs.
• A limit is set on out-of-pocket costs for patients, ensuring that coinsurance for these services does not exceed the inpatient hospital deductible for that year.

3. Definition of High Supply Cost Surgical Procedures

The bill defines specified high supply cost surgical procedures as those surgical procedures that, as of 2023, are payable under Medicare when performed in an ambulatory surgical center and exceed a significant supply cost threshold. These procedures must have specific coding that identifies the supply items used.

4. Review and Revisions to Procedures

The bill mandates an annual review starting in 2028 for the list of procedures that are classified as high supply cost. The Secretary will have the authority to add or remove surgical procedures from this classification based on established criteria.

5. Office-Based Facility Definition

An office-based facility is defined in the bill as a physician's office that meets specific health and safety standards and agrees to accept Medicare payments for the covered services as full payment.

6. Provider Agreements and Enrollment

The bill makes provisions to include office-based facilities in Medicare provider agreements, ensuring that these facilities can be recognized under Medicare for the specific high supply cost surgical procedures defined in the bill.

7. Compliance with Participation Conditions

The bill enhances provisions for the Secretary to consult with state agencies regarding the conditions of participation for office-based facilities, similar to those currently in place for ambulatory surgical centers.

8. Conforming Amendments