Health Care Policy Update: CMS Releases Proposed 2027 Medicare Physician Regulation

Research evidence excerpt

Health Care Policy Update: CMS Releases Proposed 2027 Medicare Physician Regulation

with such an obvious conflict of interest as providing information on the time and

resource requirements to conduct physician services when this information may

influence their own payment. For nearly 20 years, MedPAC has expressed concern

over the influence of the AMA RUC to value services, specifically noting that CMS

has “over-relied on specialty societies with a financial stake in the process” and has

recommended that CMS establish a separate group of experts to make payment

recommendations. Given these concerns, CMS seeks comments on the following

issues:

o What, if any, evidence is there for CMS to consider regarding the

harms or challenges associated with AMA’s monopoly over CPT-4

licenses for health care entities?

o What, if any, evidence is there that the generation of CPT-4 codes

follows a process of identification of medical necessity? What

opportunities or examples from other populations, sites of care, or

international health systems could instruct a process of identification

of medical necessity in the CPT-4 code development process?

o A combination of CPT-4 and HCPCS codes were formally adopted by

HHS as the legal standard for national coding for physician and other

services as part of implementing HIPAA (45 CFR 162.1002(a)(5)). If

CMS were to revisit this standard in future rulemaking, which if any

alternatives exist to CPT-4 for CMS to consider as part of the national

coding standard for physician services? Would CMS need to specify a

separate legal standard, or could CMS allow for private competition to

supplement the existing CPT-4 coding standard?

o What objective alternatives exist, or could be developed, to maintain a