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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

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