Tuesday, May 19, 2026

The 2026 updates to CPT, HCPCS, and ICD-10 codes are now public. These revisions include new evaluation and management code structures, revised telehealth modifiers, and additions for novel drug administration and diagnostic tests. Every payer will adopt these code sets for claims with dates of service on or after January 1, 2026. Your coding team must review the final code lists and update your charge master, billing software, and encounter forms by Q4 2025. Failure to implement these changes will cause claim rejections and payment delays starting January 1.

A coalition of major commercial payers has eliminated prior authorization for 11% of services, effective over the next 60 days. The changes target routine, evidence-based services where delays are clinically inappropriate. The same group also extended continuity-of-care protections, requiring plans to cover treatments started under a previous policy for up to 90 days after a patient changes insurance. This shift will reduce administrative burden for specific high-volume services. Monitor your payer portals for updated medical policies and publish lists by July 2026. Verify that your EHR triggers prior auth checks only for services that still require them.

CMS published the final 2027 Notice of Benefit and Payment Parameters for the Affordable Care Act exchanges. The rule expands access to catastrophic health plans for all consumers, not just those under 30, which could increase patient volume with high-deductible plans. It also grants states enhanced authority to combat fraud and abuse in the individual market, likely leading to more aggressive referral patterns and stricter network adequacy reviews. For practices with a significant exchange-plan patient mix, expect shifts in patient financial responsibility and more scrutiny of referral patterns starting in the 2027 plan year.

The U.S. Supreme Court declined to hear appeals from pharmaceutical manufacturers challenging the Inflation Reduction Act's Medicare drug price negotiation program. The decision leaves the program's legal framework intact, allowing CMS to proceed with negotiating prices for the next rounds of selected drugs. This removes a major legal threat to a central cost-containment policy. The first negotiated prices are scheduled to take effect in 2027, with the list of selected drugs expected later this year. This stability means practices can expect continued pressure from Medicare to shift toward drugs with negotiated prices, potentially influencing formulary changes and prior authorization requirements from Part D plans.

A new analysis confirms that despite public pledges to streamline the process, prior authorization requirements from major commercial insurers remain complex and inconsistent. The study found wide variation in the services requiring PA, the clinical criteria used, and the documentation demanded across payers and even across different plans from the same payer. This fragmentation forces practices to maintain payer-specific workflows and creates a high administrative burden. The report underscores that insurer-led reforms have not yet resulted in operational simplification for providers. While some payers have removed PA for certain services, the overall landscape is still a patchwork that complicates revenue cycle management and delays care.