Sunday, May 24, 2026

Multiple Medicare Advantage plans are shrinking their provider networks ahead of the next enrollment cycle. This change forces patients to either absorb higher out-of-network costs or find in-network providers, which directly threatens practice patient retention. For independent clinics, this means an imminent increase in eligibility checks, patient education, and potentially out-of-network claim submissions. Watch your MA patient panel for communication from their insurers and prepare front-desk scripts to discuss network changes and referral options. The disruption will be felt most sharply during the 2026 open enrollment period starting in October.

CMS issued new guidance requiring all Medicare plans to cover screening for tardive dyskinesia, a condition caused by long-term use of antipsychotic drugs. This formalizes coverage for a previously inconsistent benefit. Billing teams must confirm payer-specific implementation dates and ensure relevant CPT codes (e.g., 96127 for brief emotional/behavioral assessment) are documented and billed appropriately for patients on chronic antipsychotics. Update your clinical checklists for psychiatric and neurology visits to include this screening and verify coverage with each patient's Medicare Advantage or Part D plan before rendering the service.

A Congressional Joint Economic Committee report estimates Medicare Advantage overpayments have reached $7 billion per year and are rising. The finding adds political pressure for payment reforms and stricter risk-adjustment audits. While this does not change immediate workflows, it signals a hardening audit environment for MA plans, which may lead to more aggressive downcoding and retrospective claim reviews passed on to providers. Practices with high MA volumes should ensure their documentation for hierarchical condition categories (HCCs) is audit-ready and monitor for any new payer policies stemming from this heightened scrutiny.

Kansas representatives are leading a push for the Rural Hospital Relief Act, a bill designed to adjust Medicare reimbursement formulas for small rural hospitals. The legislation addresses the critical financial strain on facilities with low patient volumes by modifying the Medicare inpatient prospective payment system. This follows reports of multiple rural hospital closures across several states. While the bill's fate is uncertain, it signals continued Congressional focus on the rural healthcare crisis.