Thursday, September 17, 2026

CMS announced a public meeting for new revisions to the Healthcare Common Procedure Coding System (HCPCS) Level II codes, to be held on November 19-20, 2026. This meeting is the forum where manufacturers and other stakeholders present applications for new HCPCS codes to be considered for the 2027 update. These codes cover drugs, biologicals, radiopharmaceuticals, and devices payable under Medicare Part B, and decisions made here affect claims and reimbursement for the upcoming year. Providers and suppliers who wish to apply for a new code or comment on existing applications must adhere to the registration and submission deadlines outlined in the notice. Review the CMS notice for agenda, registration details, and submission deadlines if your practice uses or supplies items requiring a HCPCS code.

New reporting details a specific case where a Medicare patient's AI-driven prior authorization request went unaddressed for 83 days, far exceeding the typical 72-hour response standard for expedited requests. This incident, part of a broader evaluation of CMS's Wiser pilot, highlights ongoing operational failures in automated systems that can delay care and stall revenue. While the pilot involves Medicare, the data point to a systemic issue where vendor-driven AI tools may not reliably meet regulatory timelines. For billing teams, this reinforces the need to manually track high-priority AI-submitted auths and maintain a robust, traditional follow-up protocol until these systems demonstrate consistent performance.

CMS finalized the calendar year 2027 amount-in-controversy thresholds for Medicare appeals. The threshold to request an Administrative Law Judge hearing will be $200, up from $190 in 2026. The threshold to request Judicial Review in federal district court will be $2,100, up from $2,000. These annual adjustments are based on the consumer price index and affect the minimum disputed amount required to advance an appeal. Billing teams handling high-dollar denials or pursuing appeals should note the new amounts, effective for appeals filed on or after January 1, 2027. The change makes the ALJ threshold slightly more accessible but maintains a significant bar for judicial review.

A new federal bill has been introduced to curb aggressive payment recoupment practices, known as 'clawbacks,' by Medicare Advantage plans. The legislation responds to complaints from providers who face post-payment audits and demands for repayment, often years after claims were paid, creating financial uncertainty and administrative burden. The bill aims to impose stricter limits on the timing and scope of these retroactive reviews. While the legislation is in early stages, its introduction signals growing congressional scrutiny of MA plan billing and audit practices that directly impact practice cash flow. Monitor the bill's progress as it could lead to new protections against retroactive denials.

CMS is adding more chronic conditions to its Accountable Care Organization Realizing Equity, Access, and Community Health (ACCESS) model for performance year 2027. The voluntary model, which began in 2025, tests advanced payments and prospective capitation for primary care services. The expansion aims to improve care coordination for a broader population. CMS officials noted the change as part of a push for cross-payer alignment. Practices participating in or considering accountable care organizations should track the model's specifics, as it signals CMS's continued shift toward value-based arrangements for chronic disease management.