What Every Private Practice Should Be Doing Now to Prepare for CY 2026

By Drew Duffy, MHA, FACHE

The Centers for Medicare & Medicaid Services (CMS) has released its proposed rule for the Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS), and with it, a clear message: change is coming—and fast. From payment redistribution and telehealth evolution to new quality reporting requirements and bundled SUD services, every private practice needs to take proactive steps now to remain financially viable, compliant, and positioned for success.

Here’s what every private medical, behavioral health, and allied health practice should be doing right now to get ready for 2026.

1. Analyze Your Current Medicare Revenue Exposure

Start by understanding exactly how much of your practice’s revenue is tied to Medicare Part B. Then model the projected impact of:

• The updated conversion factor

  • Proposed: $33.59 for APM participants; $33.42 for all others

  • This reflects a ~3–4% increase, but not all services will benefit equally.

• RVU changes and redistribution

  • CMS is shifting value away from high-volume, procedural services and toward primary care, behavioral health, and chronic care management.

  • Specialty practices may see flat or even negative payment adjustments.

▶ Action Step: Have your billing team or consultant run a CPT-level analysis comparing CY 2025 vs. proposed CY 2026 payment rates.

2. Upgrade Your Telehealth Program

Telehealth is no longer a pandemic workaround—it’s a core part of CMS’s care delivery strategy. Key 2026 updates include:

• Permanent removal of frequency limits for inpatient and SNF telehealth

• Permanent adoption of “virtual direct supervision” for most services

• Expanded billing rights for telehealth in FQHCs/RHCs through 2026

• In-person visit requirements returning for SUD and mental health services

▶ Action Step: Ensure your telehealth documentation, coding, supervision protocols, and platform capabilities are updated to meet 2026 rules. If you bill under incident-to or supervise NPs/PAs remotely, confirm your workflows support real-time audio-video compliance.

3. Prepare for SUD & Behavioral Health Expansion

CMS is continuing its investment in behavioral health and substance use disorder (SUD) services. That means more opportunity—but also more scrutiny.

• Codes G2086–G2088 remain central for monthly SUD treatment

• New bundled models for integrated behavioral health are being prioritized

• Audio-only visits remain billable (in specific contexts), but with documentation and risk assessment requirements

▶ Action Step: Train clinicians and front office teams to identify eligible patients, document appropriately, and bill these codes correctly. Build in-person exceptions into your EHR if you rely on audio-only care.

4. Assess Alternative Payment Model (APM) Readiness

If you’re not already in an APM, CY 2026 may be the year to transition. Why?

• Higher conversion factor for qualifying APM participants

• More favorable MIPS exemptions

• Better access to value-based contracts through networks or ACOs

▶ Action Step: Evaluate whether your practice could qualify through a Medicare Shared Savings Program ACO or PCMH arrangement—or partner with an IPA or management service organization (MSO) that offers access to APMs.

5. Clean Up Coding and Documentation

Quality and risk-adjustment payment will rely more heavily on coding accuracy than ever before.

• HCC coding is central for value-based arrangements

• Under-coded chronic conditions could reduce reimbursements

• Improper documentation of time-based or incident-to services will be red flags under post-PHE audit protocols

▶ Action Step: Conduct an internal audit now—or partner with ClearPath—for a compliance and coding review focused on high-volume Medicare services.

6. Update Compliance & Training Policies

Regulatory and payer scrutiny is increasing. CMS’s proposed rule indicates more transparency and accountability measures in:

• Virtual care supervision

• Behavioral health integration

• Use of non-physician providers

• Quality reporting and cost efficiency metrics

▶ Action Step: Update staff training modules and compliance manuals to reflect CY 2026 expectations. Make sure providers know the latest on telehealth, supervision, and time-based documentation.

7. Prepare a Comment or Advocacy Plan

CMS is accepting public comment on the proposed CY 2026 rule through September 12, 2025. If there’s a change that could negatively affect your practice—or an area where clarification is needed—now is the time to speak up.

▶ Action Step: Coordinate with your specialty society or submit a comment directly through Regulations.gov.

How ClearPath Compliance Can Support Your Transition

Our team works with independent and small group practices to navigate complex CMS changes, providing:

• CPT & RVU payment modeling

• Telehealth and SUD compliance planning

• APM evaluation and alignment

• Credentialing and enrollment for expanded Medicare services

• Staff training and documentation toolkits

📩 Contact us at info@clearpathcompliance.org or call 1-888-996-8376 to schedule your CY 2026 readiness assessment.

Let us help you focus on what matters most—your patients. We’ll handle the paperwork.

-Drew

Preparing for the Fallout: How the 2025 Medicaid Cuts Will Impact Healthcare Providers

By: Drew Duffy, MHA, FACHE

Introduction The upcoming 2025 Medicaid budget reductions are poised to create deep and lasting impacts across the U.S. healthcare system—particularly for small practices, rural clinics, and providers who serve low-income populations. With over 90 million Americans enrolled in Medicaid at some point in the past two years, these cuts are not merely fiscal; they carry substantial implications for access, continuity, and equity in care.

This article presents a comprehensive overview of the proposed changes, examines the vulnerable segments within the provider landscape, and outlines key strategies that healthcare organizations can adopt to navigate the impending challenges.

I. Context and Drivers of the 2025 Medicaid Cuts The 2025 federal budget proposal includes significant Medicaid reductions aimed at curbing long-term healthcare expenditures. Several macroeconomic and political factors have catalyzed these proposed changes:

• Post-Public Health Emergency (PHE) Redetermination: Following the expiration of the PHE, states have resumed annual eligibility verifications, resulting in widespread disenrollments.

• Transition to Block Grants and Waivers: Some states are exploring capped funding models through Section 1115 waivers, shifting financial risk to providers.

• Cost-Containment of Optional Benefits: States are reassessing the provision of services such as dental, vision, and behavioral health under the "optional benefits" category.

• Increased Federal Scrutiny: CMS is tightening enforcement around medical necessity, improper payments, and state Medicaid program audits.

The combined effect is projected to reduce federal Medicaid contributions by over $200 billion across the next decade.

II. High-Risk Provider Segments The ramifications of these budgetary contractions will not be evenly distributed. Certain provider categories are particularly vulnerable:

• Small and Independent Practices: Often reliant on Medicaid as a primary payer, these clinics may face immediate revenue shortfalls.

• Behavioral Health and SUD Treatment Providers: These providers, already underfunded, may see reduced support for vital services.

• Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): Operating in underserved areas, these entities are more susceptible to reimbursement delays and care disruptions.

• Maternal, Pediatric, and Geriatric Specialists: Serving demographics heavily dependent on Medicaid, these providers could experience higher denial rates and administrative burdens.

• Clinics Serving Marginalized Communities: LGBTQ+, BIPOC, and immigrant-focused practices may struggle to retain care continuity as patient eligibility is terminated.

III. Compliance, Reimbursement, and Operational Risks As Medicaid funding contracts, enforcement activity often intensifies. Providers should anticipate the following compliance and operational challenges:

• Increased Prepayment Review and Denials: Expect elevated scrutiny of prior authorizations and coding accuracy.

• Documentation and Audit Vulnerabilities: Poor documentation can lead to recoupments, civil penalties, and exclusion.

• Eligibility Verification Complexities: Redetermination errors could lead to retroactive denials if staff are not trained appropriately.

• Revenue Cycle Volatility: Clinics may face cash flow interruptions due to longer processing times and reduced state funding matches.

IV. Strategic Recommendations for Providers Proactivity is key to mitigating the risks associated with the Medicaid cuts. Providers should consider the following actions:

1. Conduct a Payer Mix Analysis: Determine your clinic's Medicaid dependency and assess revenue diversification opportunities.

2. Update Eligibility and Billing Workflows: Train staff to manage redetermination, prior authorizations, and appeal processes efficiently.

3. Strengthen Compliance Infrastructure: Implement robust internal audit programs and regular documentation reviews.

4. Engage with Community Partners: Collaborate with local organizations to support patients during eligibility transitions.

5. Seek Federal and State Grant Support: Explore HRSA, ARPA, and state innovation funds for supplemental operational support.

6. Implement Scalable Telehealth Solutions: Use technology to reduce overhead while maintaining access and quality.

7. Consult with Reimbursement and Compliance Experts: External advisory can help avoid costly missteps and guide regulatory adaptation.

Conclusion The 2025 Medicaid cuts will be more than a fiscal correction; they will redefine the delivery landscape for providers who care for America’s most vulnerable. Clinics that respond strategically—by improving compliance, training staff, and streamlining operations—will be better positioned to sustain their mission.

At ClearPath Compliance, we support clinics through transitions like these, offering regulatory guidance, audit preparation, and strategic risk management tailored to Medicaid-participating providers. With over two decades of experience in healthcare compliance and operational resiliency, we help ensure your practice doesn’t just survive—it thrives.

-Drew