If your practice operates as a federally qualified health center (FQHC) or rural health clinic (RHC) and you have been billing home telemonitoring services, there is a coding change you need to act on immediately.
Effective April 28, 2026, for all dates of service on or after January 01, 2026, home telemonitoring providers at federally qualified health centers and rural health clinics are required to use procedure code S9110 paired with modifier U3 when submitting or resubmitting claims to the Texas Medicaid and Healthcare Partnership. Procedure code G0511, which was previously used for these services, has been discontinued and should no longer appear on any claims going forward.
The Texas Health and Human Services Commission has stepped in to ease the transition by waiving both the 95-day filing deadline and the 120-day appeal deadline for affected claims. Additionally, Texas Medicaid & Healthcare Partnership (TMHP) will automatically identify and reprocess claims with dates of service from January 01, 2026, onward. Providers do not need to file appeals unless a claim is denied for reasons beyond this coding issue after reprocessing wraps up.
One thing worth keeping in mind: Texas Medicaid managed care organizations (MCOs) operate differently from traditional fee-for-service Medicaid. Administrative processes including prior authorization, precertification, referrals, and claims filing can vary significantly from one MCO to another. If you are enrolled with an MCO, contact them directly for guidance specific to your plan.
The federal government is intensifying its crackdown on Medicaid fraud, and no state is getting a pass.
On April 21, Centers for Medicare and Medicaid Services Administrator Mehmet Oz announced at Politico's Public Health Care Summit that all 50 states have 30 days to submit provider revalidation plans. The directive is straightforward: states must immediately audit and verify every provider being paid through their Medicaid programs, with a specific focus on high-risk areas. The end goal, as Oz put it, is confirming that all Medicaid providers are legitimate.
This is not entirely new territory. Federal regulations have long required state Medicaid agencies to revalidate providers at least once every five years. What is new is the urgency. Centers for Medicare and Medicaid Services (CMS) is no longer willing to wait for the next scheduled cycle. States are being asked to demonstrate compliance now, and they are being told to lean on advanced technology and data analytics to get there. As Oz noted during the summit, data is what points officials to where the fraud actually is.
For providers, the message is clear. If your enrollment records are not clean and your billing and documentation practices cannot hold up under scrutiny, now is the time to get ahead of it. Further details on the initiative are expected to follow shortly.
Effective October 01, 2026, prior authorization will be required for HCPCS code J2860, Injection, siltuximab, 10 mg, when administered in an outpatient setting for the treatment of a cancer diagnosis.
| HCPCS code | Description |
| J2860 | Injection, siltuximab, 10 mg |
This update is being made to align with procedure code changes from CMS and/or the American Medical Association.
The prior authorization requirement will apply to:
Providers with questions can contact UnitedHealthcare oncology support by emailing unitedoncology@uhc.com, visiting the Oncology Prior Authorization and Notification page, or calling oncology prior authorization support at 888-397-8129.
Beginning August 01, 2026, Synapse Health will manage the ordering and fulfillment process for certain durable medical equipment, or DME, in Alabama, Arkansas, and South Carolina for Dual Special Needs Plans, also known as D-SNPs. The update will also apply to Chronic Special Needs Plans, or C-SNPs, in Arkansas.
Synapse Health currently manages DME ordering and fulfillment for individual HMO and PPO UnitedHealthcare Medicare Advantage plans in these three states, as well as C-SNPs in Alabama and South Carolina.
This change will not apply to the following Medicare Advantage plans:
UnitedHealthcare recognizes that this update changes the existing provider network and the current DME ordering and fulfillment process.
Based on feedback from providers and members, there is an opportunity to improve the overall experience for ordering physicians, DME suppliers, and members.
This expansion builds on Synapse Health’s existing DME management work for other Medicare Advantage products in Alabama, Arkansas, and South Carolina.
Starting August 01, 2026, DME managed by Synapse Health should be prescribed through the Synapse Health e-prescribing portal.
In the coming months, a Synapse Health representative will contact prescribers to answer questions and provide support. Prescribers may also schedule personalized training or access self-help resources through the Synapse Health website.
For members who need ongoing DME services after August 1, 2026, Synapse Health will work with current DME providers to help maintain continuity of care or support a transition to a new DME provider when needed. Synapse Health may also contact prescribers if a new order or additional documentation is needed to support the patient’s continued DME needs or plan of care.
Most DME providers that have not already joined the Synapse Health network will need to do so in order to continue providing standard DME for most UnitedHealthcare Medicare Advantage plan members.
Synapse Health will contact DME providers with information about joining its network. Providers may also email JoinOurNetwork@synapsehealth.com for more details.
Providers with questions can visit Synapse Health or call 888-336-9363 for assistance.
Beginning August 01, 2026, UnitedHealthcare will expand its Provider Administered Drugs Site of Care Policy to include select oncology medications used for maintenance therapy or monotherapy. This update is intended to support access to clinically safe, high-quality injectable medication care in the most appropriate care setting based on each member’s needs.
These medications already require prior authorization to confirm medical necessity. Under the updated policy, the site of care review will become part of the existing prior authorization process. The change will apply to UnitedHealthcare commercial plans, including Fully Insured, Level Funded, and ASO plans.
For members in the maintenance phase of cancer treatment, any prior authorization request for one of the included medications to be given in an outpatient hospital setting will be reviewed to confirm whether:
The medication is medically necessary.
The outpatient hospital setting is medically necessary.
If the outpatient hospital setting is not considered medically necessary, UnitedHealthcare will allow two administrations of the medication in that setting once the member begins the monotherapy phase. This is to help monitor for any possible adverse reactions.
If an adverse reaction occurs, continued administration in the outpatient hospital setting may be authorized.
If the medication was originally given along with chemotherapy and no adverse reaction occurred, prior authorization may be approved for an alternate site of care starting with the first monotherapy infusion.
Providers can connect through chat 24/7 in the UnitedHealthcare Provider Portal.
CMS is looking to bring back the Comprehensive Care for Joint Replacement model, but in a much larger form.
The new version is called Comprehensive Care for Joint Replacement Expanded, or CJR-X. If CMS moves forward with it, most acute care hospitals in the U.S. would have to take part starting October 1, 2027.
The model would apply to many hip and knee replacement cases. In simple terms, CMS wants hospitals to take more responsibility for what happens during the full care period, not only during the surgery.
CMS first started the CJR model in 2016. It applied to selected hospitals in certain metro areas.
The idea was simple. When a patient had a hip or knee replacement, CMS looked at the full episode of care. That included the hospital stay and the care after discharge, such as rehab, therapy, skilled nursing, home health, and follow-up care.
CMS then compared the hospital’s total spending with a target price.
If the hospital kept costs below the target and met quality rules, it could receive an extra Medicare payment. If spending went above the target, the hospital could owe money back to Medicare.
This did not change how providers were paid during the episode. Doctors, hospitals, and other providers still received normal Medicare payments under systems like IPPS, OPPS, and the Physician Fee Schedule. The comparison happened later, after CMS reviewed the total episode cost.
CMS later found that the original model produced modest savings. It also did not show major harm to care quality. Post-acute spending went down in some cases, while complications, readmissions, and mortality did not increase.
That is one reason CMS now wants to bring the model back and expand it nationwide.
If finalized, CJR-X would apply to most acute care hospitals in all 50 states, Washington, D.C., and U.S. territories.
The model would include hospitals that perform qualifying lower extremity joint replacement procedures and are paid under both:
CMS is using this rule because joint replacement cases may start in the hospital or in an outpatient department.
Some hospitals would not be included, such as:
For hospitals that qualify, participation would be required unless CMS changes the model or the hospital no longer meets the rules.
CJR-X would focus on lower extremity joint replacement procedures. That mainly means hip and knee replacements.
An episode would begin with an anchor event. This could be an inpatient hospital stay or a qualifying outpatient procedure.
The proposed codes include:
Each episode would last 90 days.
For inpatient cases, the count would begin after discharge. For outpatient cases, it would begin on the procedure date.
CMS says the 90-day window worked in the earlier CJR model and also matches the global surgical period used under the Medicare Physician Fee Schedule.
CMS wants the episode to include most Medicare Part A and Part B services tied to the joint replacement.
That may include:
The point is to look at the full cost of care. CMS does not want hospitals to focus only on the surgery and ignore what happens after the patient leaves.
Some services would be left out, especially if they are not related to the joint replacement. CMS may also exclude certain high-cost drugs or technologies that are paid separately.
CMS would use five quality measures in CJR-X.
These include:
These measures would be combined into one Composite Quality Score, also called CQS.
The score would be weighted like this:
This score would matter for payment. A hospital would not be judged on cost alone.
CMS would set target prices before each performance year.
Those prices would be based on three years of regional Medicare claims data. CMS would look at the type of episode and the hospital’s region.
The pricing method would also include risk adjustment, trend updates, a 2% discount factor, and caps for very high-cost cases.
In basic terms, CMS would estimate what a joint replacement episode should cost in that region. Later, it would compare the hospital’s actual spending with that estimate.
Hospitals would start with a 2% discount factor. That is the saving Medicare expects under the model.
A hospital with better quality scores could reduce that discount. A hospital with weak quality scores could lose access to reconciliation payments.
The proposed categories are:
So, even if a hospital lowers costs, it still needs to protect patient outcomes and experience.
After each performance year, CMS would compare actual episode spending with the hospital’s target price.
If spending is below the target and quality is strong enough, the hospital may receive a one-time Medicare payment.
If spending is above the target, the hospital may have to repay Medicare.
For most hospitals, gains and losses would be capped at 20% of the hospital’s total target price.
Rural hospitals and safety-net hospitals would have more protection. Their stop-loss limit would be 5%.
CMS also plans to watch spending during the 30 days after the episode ends. This is meant to prevent providers from pushing needed care outside the 90-day window.
The proposal would allow hospitals to work with physicians and other providers through formal arrangements.
These partners could include surgeons, physician groups, skilled nursing facilities, home health agencies, inpatient rehab facilities, long-term care hospitals, therapy groups, Medicare ACOs, and other providers.
Hospitals may be able to share savings with these partners through gainsharing payments. Some partners may also share downside risk through alignment payments.
CMS would require written agreements and other safeguards. Payments could not be based on referral volume or unrelated business.
Because these arrangements can raise fraud and abuse concerns, CMS says certain waivers or safe harbor protections may apply. Hospitals would still need to structure these agreements carefully.
This proposal could affect how hospitals manage joint replacement care.
Hospitals may need to look more closely at:
Hospitals that already track these areas may have an easier time adjusting. Hospitals that do not may need to build stronger systems before the model starts.
CMS is proposing to bring back the joint replacement payment model and expand it across the country.
If finalized, CJR-X would begin on October 1, 2027. It would make many hospitals responsible for the cost and quality of hip and knee replacement care over a 90-day period.
The model rewards hospitals that manage care well and meet quality expectations. It also creates repayment risk for hospitals with higher spending.
For hospitals, surgeons, and post-acute providers, the message is clear: CMS wants more care coordination, tighter episode management, and better control over the full cost of joint replacement care.
CMS Administrator Dr. Mehmet Oz has asked state Medicaid directors to create and submit two-year provider revalidation plans as part of a wider effort to reduce healthcare fraud.
The request asks each state to explain how it checks provider enrollment data and keeps that information accurate. This includes regular revalidation and any other steps the state uses to confirm that Medicaid providers are still eligible to take part in the program.
CMS said most Medicaid providers are honest and focused on patient care. At the same time, the agency warned that some groups are using gaps in the system to make money through fraud.
The letter also asks states to increase checks on providers that fall under the high-risk category. CMS wants these providers reviewed more often than the usual five-year minimum. The agency also wants states to focus soon on high-risk providers who have not been screened in the past 12 months.
CMS also expects states to explain how they review providers who do not have a National Provider Identifier, or NPI.
States have been asked to inform CMS within 10 days if they plan to revalidate high-risk providers. They also need to submit full two-year revalidation strategies within 30 days of receiving the letter.
The request comes as CMS increases its focus on Medicaid fraud in several states, including Minnesota, New York, California, Florida, and Maine. Home and community-based services may be one area that receives more attention under this effort.
Damon Terzaghi of the National Alliance for Care at Home said personal care and related home care services will likely be a key part of this initiative. He also noted that many states have fallen behind on provider revalidation because of heavy workloads, COVID-19 pressures, and changes in Medicaid over recent years.
When states fall behind on revalidation, it can create weak spots in program oversight. Regular provider checks help confirm that Medicaid records are accurate and that only eligible providers remain active in the program.
During the 2026 annual HCPCS code update, CMS removed procedure code G0512, which FQHCs and RHCs previously used for Collaborative Care Model services. This change became effective on January 01, 2026.
Starting June 01, 2026, Texas Medicaid will allow FQHC and RHC providers to use CoCM procedure codes 99492, 99493, 99494, and G2214 for claims with dates of service on or after January 01, 2026.
Texas Medicaid may pay these CoCM codes separately from the regular FQHC or RHC encounter rate. This means eligible providers may receive reimbursement for these services in addition to their standard encounter payment.
TMHP will also review claims submitted by FQHC and RHC providers before June 1, 2026, that were affected by this code change. If a claim needs to be adjusted, the updated payment details will appear on a future remittance and status report.
For questions, providers can contact the TMHP Contact Center at 800-925-9126.
Note: Providers working with Texas Medicaid managed care members should also check with the member’s specific MCO. Each MCO may have its own rules for prior authorization, referrals, precertification, claims, and encounter data submission.
CMS and the FDA have started a new process called the RAPID Coverage Pathway. RAPID stands for Regulatory Alignment for Predictable and Immediate Device Coverage.
The idea is to make Medicare coverage faster for some breakthrough medical devices.
A device can get FDA approval, but patients may still have to wait for Medicare coverage. That wait can create problems for patients, doctors, hospitals, and device companies.
With RAPID, CMS and the FDA plan to work together earlier. This should help reduce the gap between FDA approval and Medicare coverage.
The new pathway applies to certain FDA-designated Class II and Class III breakthrough devices. These are devices that may help patients with serious conditions or medical needs who do not have enough treatment options.
Through RAPID, CMS will work with the FDA and device manufacturers while the device is still being developed. This gives manufacturers a clearer idea of what evidence Medicare may need before deciding coverage.
That matters because FDA approval and Medicare coverage are two different steps. The FDA looks at whether a device is safe and effective. CMS looks at whether Medicare should cover and pay for it.
When both agencies align earlier, companies can plan better studies and avoid delays later.
For Medicare patients, the biggest benefit is faster access.
Some new devices can make a real difference in care, but patients may not benefit quickly if coverage decisions take too long. RAPID is designed to make the coverage process more predictable after FDA authorization.
For manufacturers, it may also reduce confusion. Instead of waiting until the end of the FDA process to understand Medicare expectations, companies can get CMS input earlier.
That can help them collect the right clinical data from the start.
The pathway is not for every medical device.
It is meant for certain breakthrough devices that address unmet needs among Medicare beneficiaries. Eligible devices must also be part of an Investigational New Drug study, known as an IDE study.
That study must include Medicare beneficiaries and must track clinical outcomes that both CMS and FDA agree are important.
In simple terms, the device company must show evidence that matters for real Medicare patients, not just for approval paperwork.
Under the RAPID pathway, CMS plans to issue a proposed National Coverage Determination on the same day an eligible device receives FDA market authorization.
After that, there will be a 30-day public comment period.
CMS says this process could allow Medicare coverage and payment as soon as two months after FDA authorization. That is much faster than the usual process, which can take around a year or more in some cases.
CMS said it will still keep its other Medicare coverage options available. This includes the normal process for national coverage decisions.
However, CMS will pause new candidates for the Transitional Coverage for Emerging Technologies pathway, also called TCET, while it focuses on RAPID.
The agency says it will use what it learns from these pathways to improve Medicare coverage decisions over time.
CMS will publish a proposed notice about the RAPID pathway in the Federal Register. The public will then have 60 days to submit comments.
After reviewing those comments, CMS will publish a final notice. The pathway is expected to begin once that final notice is published.
The RAPID Coverage Pathway is CMS's and FDA’s attempt to make Medicare coverage faster and clearer for certain breakthrough medical devices.
By working together earlier, both agencies aim to reduce delays, give manufacturers better guidance, and help Medicare patients access new technologies sooner.
The Centers for Medicare & Medicaid Services has released its proposed updates for the Medicare Advantage and Part D programs for 2027. These changes may look technical, but they could have a real financial effect on health plans, providers, and investors involved in Medicare Advantage.
CMS expects Medicare Advantage plans may see a payment increase of around 2% to 4%, depending on the final rates and each plan’s situation. Even a small change in that range can mean a large shift in revenue. For some organizations, it could affect millions of dollars each year.
The bigger issue is not just whether payments go up or down. It is also about how CMS plans to review those payments and how much risk organizations may face if their coding or documentation does not meet the required standards.
One of the biggest parts of the proposal is CMS’s continued update of the risk adjustment model used to set Medicare Advantage payments. The agency is moving ahead with revised Hierarchical Condition Categories, also known as HCCs, and continues to reduce the effect of coding intensity on payment.
CMS is also making its position clear on documentation. Diagnoses used for payment must be supported by medical records created at the time of care and must reflect conditions that were active and addressed.
This matters because some organizations have relied heavily on coding practices that increase risk scores. CMS is now trying to make sure those scores better match the patient’s true clinical condition. As a result, some diagnoses may carry less payment value, and some organizations may see lower risk scores unless their records strongly support the conditions reported.
CMS is also placing more focus on audits and program integrity. The agency continues to expand Risk Adjustment Data Validation audits and is paying closer attention to diagnosis reporting and supporting records.
In simple terms, this means payments linked to diagnosis coding are facing more review. Coding done after a patient visit, especially through chart reviews or outside vendors, may bring in more revenue in the short term. But it also creates more risk if the records do not fully support the diagnosis.
This is no longer just an audit issue. In some cases, it can also lead to False Claims Act investigations. Federal agencies are looking closely at whether retrospective coding practices have led to unsupported diagnoses and higher payments than allowed. That can result in repayment demands, penalties, and in serious cases, even criminal exposure.
These changes may have a wide effect because Medicare Advantage now covers a large share of Medicare beneficiaries. When CMS changes payment methods, even slightly, the impact can spread across the healthcare system.
Providers and healthcare groups that depend heavily on risk-adjusted revenue may feel the most pressure. This is especially true for organizations that rely on high coding intensity or retrospective diagnosis capture. Even a small drop in risk scores can lead to a meaningful drop in revenue when large patient populations are involved.
Health plans may also respond by pushing more responsibility onto providers through contracts and closer coding oversight. In some arrangements, providers may have to absorb the financial impact of unsupported diagnoses, even if the coding work involved a health plan or a third-party vendor.
These proposed changes also matter for private equity firms and other healthcare investors. Many healthcare platforms now depend heavily on Medicare Advantage revenue.
That means investors need to look beyond headline payment increases. They also need to examine how stable that revenue really is. If growth has been supported by aggressive coding or retrospective review programs, the real question is whether that revenue can hold up under audit and compliance review.
Changes in payment policy and stronger enforcement can affect both current cash flow and future valuation. For that reason, documentation quality and compliance strength are becoming more important in investment analysis.
CMS’s 2027 proposals show that Medicare Advantage is moving toward tighter payment review and stronger oversight. The goal is to improve payment accuracy and reduce unsupported claims. For providers, health plans, and investors, the message is clear: revenue strategy and compliance can no longer be treated as separate issues.
Organizations that review their coding practices, documentation standards, and financial exposure now will be better prepared for what comes next
