Saturday, July 18, 2026

CMS has proposed ending Medicare reimbursement for remote patient monitoring (RPM) and remote therapeutic monitoring (RTM) services provided by third-party vendors, a major operational shift. The proposal, included in the CY 2027 Physician Fee Schedule rule, responds to OIG scrutiny and would require that the billing practitioner's staff personally furnish the services. This directly targets the current industry model where practices often contract with external vendors to manage RPM for chronic care patients. The change would affect CPT codes 99453, 99454, 99457, 99458, 98975, 98976, 98977, and 98980. Comments on the proposed rule are due by September 5, 2026. Review your current RPM vendor contracts and assess the in-house staffing impact if this rule is finalized.

A Senate Republican bloc has defeated a bid to repeal CMS's Medicare prior authorization pilot that tests AI-driven review tools. The pilot, which began in 2025, applies to certain hospital outpatient department services and has drawn sharp criticism from provider groups over increased denials and lack of transparency. The failed repeal means the demonstration will continue as scheduled, potentially paving the way for broader adoption of algorithmic prior auth systems in Medicare. This signals that AI-driven utilization management tools will remain a core feature of payer workflows. Monitor CMS-2025-XXXX for any updates to the demonstration's scope or published denial-rate data.

CVS Health CEO David Joyner stated private health plans will continue to largely exclude coverage of GLP-1 drugs like Wegovy and Zepbound for weight loss until manufacturers lower prices. His comments reflect the mounting financial strain these drugs place on employer-sponsored plans, with some analysts projecting annual costs exceeding $100 billion if coverage expands broadly. This stance signals a prolonged access battle for patients seeking anti-obesity medications outside Medicare's limited GLP-1 Bridge program. Practices should expect strict prior authorization criteria and high patient cost-sharing for these drugs on commercial plans for the foreseeable future, complicating treatment initiation and adherence discussions.

A federal judge in Maryland issued a stay blocking two Trump administration rules that would have reduced the number of navigators helping consumers enroll in Affordable Care Act plans and loosened network adequacy standards for 2027. The rules, finalized in May, were challenged by multiple state attorneys general who argued they would undermine marketplace stability and consumer protection. The stay halts implementation pending further litigation, preserving the current regulatory framework for the upcoming open enrollment period. This ruling prevents immediate disruption to ACA enrollment assistance, but the underlying legal fight over the scope of federal marketplace regulation continues. Track the case, *California v. Kennedy*, for the final outcome.