The Centers for Medicare & Medicaid Services (CMS) recently released the Calendar Year (CY) 2026 Final Rule, introducing updates that will impact payment, telehealth, quality reporting, and compliance. For clinicians, coders, and practice administrators, understanding these changes is critical to ensure accurate reimbursement and maintain regulatory compliance.
Payment Policy Updates
- Physician Fee Schedule (PFS): The conversion factor increases by 2.5%, with additional adjustments of 0.75% for qualifying Alternative Payment Models (APMs) and 0.25% for non-qualifying APMs.
- Hospital Inpatient Prospective Payment System (IPPS): Acute care hospitals that utilize EHRs and meet IQR Program requirements will see a 2.6% increase in operating payments. This reflects a 3.3% market basket increase, offset by a 0.7% productivity adjustment.
- Hospital Outpatient Prospective Payment System (OPPS): Hospitals meeting quality reporting requirements can expect a 2.4% increase, based on a 3.2% projected market basket increase minus a 0.8% productivity adjustment.
Telehealth Policy Adjustments
- Expanded Telehealth Services: New codes now cover mental health counseling, chronic disease management, and additional services.
- Originating Site Flexibility: Patients can access telehealth from a wider range of locations.
- Payment Parity: Certain telehealth visits will be reimbursed at the same rate as in-person care, supporting continued access to virtual services.
Quality Reporting Enhancements
- Health Equity Measures: New quality metrics aim to identify and reduce disparities in care.
- Star Ratings Adjustments: Updates to Medicare Advantage Star Ratings provide a more accurate reflection of plan performance and patient outcomes.
- Expanded Reporting Requirements: Providers must submit additional data elements, increasing transparency and the comprehensiveness of quality assessments.
Compliance and Oversight
- Enhanced Oversight of Medicare Advantage Plans: Stricter auditing and penalties will apply for non-compliance.
- Provider Directory Accuracy: MA plans are required to update provider directory information within 30 days of changes and attest to its accuracy annually.
- Appeals Process Clarifications: MA appeals rules now apply consistently to all adverse plan decisions, safeguarding patient rights.
Taking Action for 2026
Staying up to date with these changes is more than a compliance exercise—it’s essential for optimizing workflows, coding accuracy, and overall practice efficiency. Reviewing the Final Rule, updating internal policies, and educating staff are critical first steps.
For practices ready to move beyond awareness and take proactive steps, BCA’s audit, education, and consulting services provide the guidance and tools needed to turn these regulatory updates into actionable improvements. From targeted provider education to documentation and coding audits, our team helps clinics ensure they’re fully prepared for 2026 and beyond.
Looking Ahead
Next week, we’ll focus specifically on RVU Value Changes for 2026.
By staying ahead of the CMS Final Rule, your practice can maintain compliance, optimize revenue, and provide uninterrupted, high-quality care.
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