Same Scan, Triple the Price: What CMS's Site-Neutral Imaging Proposal Means for Montana Providers
Every so often, Washington confirms something Montana providers already knew. It happened on July 2, when the Centers for Medicare and Medicaid Services released its proposed hospital outpatient payment rule for 2027. Tucked between drug pricing changes and quality reporting updates is a proposal built on one plain idea: Medicare should not pay more for an imaging test just because of where the test happens.
The mechanics, briefly. Hospitals bill Medicare under a different payment system than physician offices, and for years the same exam has carried a very different price depending on which system it ran through. CMS has been chipping away at that gap since 2019, starting with clinic visits, then drug administration services. The 2027 proposal extends the approach to imaging without contrast performed at off-campus hospital outpatient departments. If it goes through, those departments would be paid at the physician office rate for those exams.
The number that made the trade press sit up came from CMS itself. As Radiology Business reported, the agency pointed to echocardiograms, where Medicare has been paying roughly 294 percent more in hospital settings than in offices. Same transducer, same heart, nearly triple the price. CMS put it plainly in its fact sheet: patients should not pay more for an imaging test solely because of the site where care was furnished.
The dollars are not small. CMS estimates the change would trim about $260 million from Medicare imaging spending in its first year. Roughly $190 million of that is program savings. Another $70 million shows up as lower premiums for patients, and cost sharing obligations are projected to drop by about $70 million on top of that.
A few caveats belong up front. This is a proposed rule, not a final one. The comment period is open, and a final rule typically lands in the fall before taking effect the following January. Rural Sole Community Hospitals would be exempt, which matters in Montana, where many small hospitals carry that designation. And nothing in this post is billing or coverage advice. Payer rules vary by patient, plan, and order. When in doubt, ask your billing team, not a blog.
The part of the equation the rule does not touch
So why write about a payment rule at all? Because the argument underneath it is the one we have with clinic managers and facility directors every week: the setting where imaging happens shapes everything downstream. Washington is focused on the price tag. Providers live with the rest of it.
Think about what an off-site echo actually costs a skilled nursing facility, beyond the claim. A resident gets scheduled weeks out. On the day, a van has to be arranged and a staff member pulled from the floor to ride along. The resident spends half a day in transit and waiting rooms, which for a frail patient can mean a missed meal, a missed med pass, and a rough night afterward. If the appointment gets bumped, the whole machine resets. None of that shows up in a payment rate, but every facility director can price it from memory.
Clinics feel a smaller version of the same thing. A provider orders an ultrasound, the patient gets referred across town, and somewhere between the referral and the appointment a share of patients simply falls off the schedule. The scan that was supposed to answer a question ends up delaying the answer instead.
Move the machine, not the patient
Our model starts from the opposite premise. Big Sky Imaging brings X-ray, ultrasound, echocardiography, and EKG directly to clinics, skilled nursing facilities, and other care sites across Montana. In covered markets, X-ray and EKG are available same day. When an order comes in, Kate, our dispatcher in Eureka, assigns a regional technician. Images are interpreted by Rapid Radiology's board-certified teleradiology network, and reports flow back to the ordering provider. The resident stays put, and the exam comes down the hall instead.
To be fair about scope: the CMS proposal addresses what Medicare pays certain hospital departments. It does not change what your patients go through getting to and from a scan, and it does not add a single appointment slot in a market where the schedule is already full. Site-neutral payment is a fairness question on the invoice. On-site imaging is a logistics question at the bedside. A practical imaging strategy has an answer for both.
It is also worth saying that hospital outpatient departments are not the villain here. They carry standby capacity, emergency coverage, and overhead that offices and mobile services do not. The policy debate is about which exams truly need that setting. For a routine chest X-ray on a stable nursing home resident, or a scheduled echo on a cardiology patient who lives forty minutes from town, there is a strong case that they do not.
What to watch
If the rule is finalized this fall, the new imaging payment policy would take effect in 2027, and hospital systems will spend the next year deciding how to respond. Some will consolidate imaging on campus. Some will rethink which services belong in which buildings. Either way, ordering providers in Montana will keep asking the same operational question they ask now: for this patient, does it make more sense to move the person or to move the machine?
For a growing number of exams, moving the machine wins. That was true before July 2, and it will be true whatever the final rule says.
This post is for general information only and is not medical or billing advice. Imaging decisions belong with the ordering provider, and coverage questions belong with the payer.
If you run a clinic or care facility in Montana and want to see how on-site ordering works in your region, reach out. We will walk your team through the workflow and confirm current availability in your market.
