The Centers for Medicare & Medicaid Services (CMS) recently announced a proposed rule for the 2026 Medicare Physician Fee Schedule. It introduces significant changes aimed at modernizing Medicare, improving patient care, and reducing costs. These changes will impact on physicians, particularly in how they manage chronic diseases and interact with Medicare billing.
#1: Focus on prevention and wellness
It should come as no surprise that President Donald Trump and the leaders he has chosen in the healthcare realm including Dr. Mehmet Oz as the Administrator for the CMS and Robert F. Kennedy Jr. as the United States Secretary of Health and Human Services (HHS) are making a push towards preventative medicine. To address this goal, the CMS proposal for 2026 includes a focus on prevention of chronic diseases, such as prescreening for diabetes and accessibility for patients to receive training on dietary changes and physical activity to help delay the onset of Type 2 diabetes.
#2: Ambulatory specialty care model
CMS’s new ambulatory specialty care model targets areas of high spending, such as low back pain and heart failure. This model incentivizes early detections, rewarding specialists for avoiding hospitalizations and working with primary care.
The shifted focus aims to improve chronic disease management and reduce costs, offering physicians new opportunities to enhance patient care while benefiting financially.
#3: Skin substitutes
This area has skyrocketed, with the CMS pointing to abusive pricing practices within this niche area of medicine as the primary culprit. To address the issue, the agency has proposed changing how it classifies medical supplies used in this field to cut costs by up to 90%, saving billions without compromising patient access.
#4: Aligning physician payments and telehealth
The agency also plans to make permanent certain current temporary telehealth coverage. These changes offer physicians more consistent payment structures and greater access to telehealth resources, enhancing their ability to provide comprehensive care.
#5: Conversion factors and payment adjustments
CMS also proposes conversion factors for 2026. Participants will see an increase of almost 4%. These adjustments aim to reflect the evolving healthcare landscape, helping to better ensure physicians receive fair compensation for their services.
CMS’s proposed changes to Medicare billing rules represent a shift in how physicians manage chronic diseases and interact with Medicare. By incentivizing early intervention, streamlining costs, and expanding telehealth, the proposal could help to modernize Medicare and improve patient care. Physicians are wise to be aware of these potential changes and make sure their billing practices are in line with current expectations to avoid allegations of an overpayment or other billing issue. It is important to point out that these proposals are still under discussion.
Attorney John Rivas is responsible for this communication.
