CMS finalized roughly a 10% increase in Chronic Care Management reimbursement across all CCM codes in the CY2026 Physician Fee Schedule — one of the larger annual increases in the program’s history — and continued expanding Advanced Primary Care Management. That is CMS saying something plainly with money: manage chronic disease between visits, and we […]
You Are Being Paid to Manage Chronic Disease. Are You Doing It? Read More »
Buried inside the WISeR model — the technology-assisted prior authorization program that launched in Original Medicare this January — is a feature that deserves far more attention than it has received. CMS plans to launch a gold carding, or exemption, program under WISeR in 2026. Providers who consistently meet coverage criteria will generally be exempt
CMS Is About to Let Some Providers Skip Prior Authorization Entirely Read More »
Last week I wrote about the ACO REACH PY2024 results, where roughly 95% of net savings came from the benchmark discount rather than ACO performance. It is worth putting the Medicare Shared Savings Program results beside them, because they tell a different and more encouraging story — with a catch. MSSP had its strongest year
There is a care-management intervention with evidence behind it for lower costs and lower mortality, a dedicated Medicare payment mechanism, and clear operational requirements — and historically it was used after fewer than one in ten eligible discharges. Transitional Care Management may be the widest gap in American healthcare between what we know works and
There is a compliance date coming that will reshape how prior authorization works across Medicare Advantage, Medicaid managed care, and the exchanges — and unlike most regulatory deadlines, this one requires building software, not writing policy. The CMS Interoperability and Prior Authorization final rule has been in motion since 2024. Its operational provisions started this
The January 2027 Deadline Most MA Plans Are Underestimating Read More »
Every risk-adjustment program I review asks the same question: are the diagnoses we submitted supported? It is the right question. It is also only half of one. The other half almost nobody asks: which patients never made it into the analysis at all? Because a patient who is invisible to your data is invisible to
The Patients Your Data Can’t See Are the Ones Who Bankrupt You Read More »