Saturday, August 22, 2026

The 2027 Physician Fee Schedule proposed rule, published this week, outlines a significant overhaul of valuation for evaluation and management services paired with minor procedures. CMS specifically targets reimbursement for modifier 25, aiming to align payment with resource use. The proposal suggests reducing payment for the E/M service when billed with a minor procedure on the same day, which would impact specialties like urology, dermatology, and primary care that frequently use the modifier. This is part of a broader budget-neutrality adjustment that also includes changes to the chronic care management code G2211. The comment period is open; practices should model the financial impact on their top 25 code pairs now.

HHS published a notice seeking public comment on a proposed information collection from health plans regarding prior authorization decisions. The agency aims to standardize the data insurers must report on approval rates, denial reasons, and appeal outcomes. This follows recent legislation and enforcement pressure to increase transparency around payer practices. For medical practices, the finalized dataset could provide a benchmark to challenge outlier denial rates and support value-based contract negotiations. The comment period is a procedural step; monitor the docket for the final instrument shape.

A coalition of Arkansas medical groups is urging the Trump administration to grant a two-year extension for the state's Medicaid expansion, which currently covers over 300,000 low-income adults. The current expansion authority is set to expire, and providers warn that a lapse would cause massive coverage losses and destabilize clinics and hospitals that have built care models around the expanded population. The request is part of a broader political negotiation around federal health funding. Monitor for an HHS decision, expected by late 2026, which will set the terms for provider networks and patient volume through 2028.

Investment firms Carlyle, Longshore Capital, and Serent Capital are actively acquiring revenue cycle management platforms, signaling a wave of private equity consolidation in the healthcare IT sector. This activity is partly driven by new federal price transparency and prior authorization rules that increase demand for sophisticated billing and claims management software. For independent practices, this consolidation may lead to platform integrations, price increases, or service changes as new owners seek returns. The trend highlights the growing financialization of the RCM middleware layer between providers and payers.

A watchdog report finds that the three largest Medicare Advantage insurers, UnitedHealthcare, Aetna, and Humana, collectively deny more than 70% of requests for long-term care services, including skilled nursing facility stays and home health aide coverage. The denials are primarily based on internal clinical criteria that are stricter than traditional Medicare's national coverage determinations. For practices managing patients transitioning from acute to post-acute care, this pattern means more frequent appeals and increased administrative burden to secure necessary authorizations. The data underscores a structural shift where MA plans aggressively manage high-cost, longitudinal services.