On this episode of 1st Speak Compliance, Kevin Chmura is joined by Robyn Johns, as they talk about current updates to their November reside webinar, Compliance Cliffs: Navigating Telehealth Waivers and Reimbursement Adjustments.
Learn the way the coverage panorama has shifted in current months—particularly round telehealth flexibilities, managed substance prescribing, and the 2026 CMS cost guidelines.
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Kevin Chmura
Welcome to 1st Speak Compliance. I’m Kevin Chmura, CEO of Panacea Healthcare Options. As we speak we’re bringing you a well timed replace on our November reside webinar, Compliance Cliffs: Navigating Telehealth Waivers and Reimbursement Adjustments.
Since that webinar, a number of coverage adjustments have moved rapidly, particularly in telehealth flexibilities. Managed substance prescribing and 2026 CMS cost guidelines. Earlier than we soar in, only a fast be aware. 1st Speak Compliance is dropped at you by 1st Healthcare Compliance, part of Panacea Healthcare Options. We assist healthcare organizations strengthen their compliance packages with sensible schooling instruments and compliance administration help. So groups can cut back danger, hold tempo with regulatory change and function with confidence.
Now I’m happy to welcome again Robyn Johns from Med USA.
Robyn, thanks for coming again.
Robyn Johns
Thanks, Kevin. I’m comfortable to be right here.
Kevin Chmura
Nice. So, let’s soar in. So, in November on the webinar, we spent numerous time on what individuals had been calling the telehealth cliff, which was creating an incredible quantity of uncertainty on whether or not flexibilities would expire. Are you able to catch us
up on what the standing is now?
Robyn Johns
Yeah. The main replace is that the spending bundle launched on January twentieth contains extensions of the telehealth flexibilities all through December thirty first of 2027.
Kevin Chmura
In order that’s a reasonably significant runway. That’s nice, however I assume doesn’t eradicate compliance obligations, however it’s lowering near-term uncertainty which give all people a while to standardize workflows. So, it’s within the information, however possibly you could possibly inform. So, what’s within the spending bundle at a excessive degree and what ought to healthcare leaders like us be taking note of?
Robyn Johns
Proper. So, it was the one from the twentieth was a $1.2 trillion spending bundle launched by the Home Appropriations Committee and it was simply handed yesterday on the twenty second in two separate votes by the total Home. So, these payments included the remaining six of the twelve appropriations essential to avert a authorities shutdown. In order that’s excellent news for everybody. If we will get them throughout the end line, they funded lots of the federal authorities businesses akin to HHS, Labor, Protection, HUD, and likewise Homeland Safety. That was a contentious one. That’s why they needed to do two separate votes. It funds them by fiscal 12 months 2026, which ends on September thirtieth of this 12 months.
Kevin Chmura
So, OK, so now we have a funding bundle with a number of healthcare coverage riders. Not, I assume not too stunning in immediately’s day and age. So, apart from the telehealth by 2027, what else is included in there that compliance and operational leaders ought to learn about?
Robyn Johns
So the writers additionally embrace PBM reform and it extends hospital at residence really by 2030, which is one other one which hit numerous amenities arduous with the federal government shutdown. It extends Medicare dependent hospital and low quantity hospital packages, which is absolutely useful for our rural suppliers and it delays the Medicaid disproportionate share reduce once more till fiscal 12 months 2028. Notably, for lots of people, it doesn’t embrace an extension of the ACA subsidies, which had been such a sticking level within the authorities shutdown final fall.
Kevin Chmura
Yeah, that that that final level is operationally actually necessary and protection instability typically turns into eligibility churn and places actual pair combine pressures on the you recognize similar sufferers, totally different protection, proper.? And that’s simply you recognize in all probability will increase downstream compliance and documentation stress. Yeah that’s a that’s a tricky one. So what’s the timing of congressional motion now?
Robyn Johns
So with the Home passing all the payments, they now ship the total appropriations bundle to the Senate. The Senate will take all of that up after they return from recess on Monday the twenty sixth, and can hopefully move all of them forward of the January thirtieth deadline. And hopefully with none vital adjustments which could require them to return to the home as a result of the home can be on recess subsequent week.
Kevin Chmura
Wow. So cut up schedule, it’s why we must always hold ourselves in a monitoring posture. I assume we must always at all times be monitoring, however issues are transferring fairly rapidly proper now and also you form of get into that world of what’s anticipated just isn’t what’s in impact.
Which is at all times, at all times a tricky place to function, however hey, that’s healthcare, isn’t it? So, given the extension to 2027, in your opinion, what ought to compliance groups be doing now? Like what’s some sensible subsequent steps?
Robyn Johns
First, you’ll wish to guarantee that your inside insurance policies and academic supplies replicate what’s at the moment in impact. No main adjustments since most of these telehealth issues had been prolonged, however it’s at all times good to double test as a result of numerous issues change across the starting of the 12 months. Additionally validate your payer particular guidelines. Medicare coverage route is influential, however industrial payers and state legal guidelines differ. So, you bought to just be sure you are matching up with these variations. After which third, we must always we speak about strengthening your auditing of documentation, the modifiers, your house of service, medical necessity, all of these issues that may fluctuate relying on the payer and the particular scenario of the affected person.
Kevin Chmura
Yeah, that that payer variation level is the place numerous organizations find yourself being uncovered, I assume, proper? Telehealth’s not likely ruled by one rule. You’ve bought federal coverage, state overlays, after which you’ve got industrial coverage updates actually coming at you a variety of other ways. So, I assume a great controls to keep up possibly a payer coverage matrix and attempt to align it into your documentation and coding steering. In all probability a stable piece of recommendation.
Robyn Johns
Completely.
Kevin Chmura
Yeah. So, let’s transfer on to in all probability one of many highest danger areas that we lined within the webinar, and that’s managed substance prescribing through telehealth. What’s the most recent there?
Robyn Johns
Excellent news there as nicely. On the finish of the 12 months, DEA and HHS prolonged the telehealth flexibilities for prescribing managed substances by this 12 months, December thirty first of 2026. There are a couple of guidelines that may apply, however as a result of they prolonged the flexibilities, it’s just about established order till they modify it once more on the finish of the 12 months.
Kevin Chmura
Cool, in order that’s a important compliance space due to the excessive danger profile and it that actually contains some regulatory scrutiny and enforcement, not likely only a reimbursement subject.
Robyn Johns
Sure, it’s extremely watched.
Kevin Chmura
Yeah. And I assume as nicely, it must be. So provided that, what management ought to organizations prioritize proper now to scale back danger in that space?
Robyn Johns
Undoubtedly you’ll wish to have clear prescribing insurance policies, good documentation requirements, and role-based coaching. Additionally, normally they wish to embrace id verification and required checks after they’re relevant, and constant auditing to make sure that your course of is adopted, not simply written down. That is one other space the place state laws can fluctuate, so you’ll wish to just be sure you are compliant in each state the place you see sufferers.
Kevin Chmura
Sure and also you’re the knowledgeable, not me. However I assume I’d add if you happen to broaden well being to if you happen to broaden the telehealth rapidly, take time now to make sure your governance is mature. And I’m considering credentialing, supervision, documentation and audit trails at all times the fundamentals that may make it easier to pulled up below scrutiny.
Robyn Johns
Undoubtedly. Once you broaden rapidly, typically you sacrifice sure issues for pace. So, you’ve got a minute now to return now that you simply’re certain that these insurance policies aren’t altering anytime quickly to simply return and guarantee that all the pieces’s in place, all of these areas.
Kevin Chmura
Yeah, I imply like all enterprise runs higher and with certainty, however at healthcare we not often have that. So, nice. So, transferring on to the 2026 CMS updates that that we talked about a bit bit.
So, there’s been some adjustments in cost coverage which are driving operational adjustments and it’s the place these operational adjustments are available, the place we introduce compliance dangers if groups can’t hold tempo and sometimes they will’t. So, what are the 2026 doctor payment schedule highlights?
Robyn Johns
Yeah. So, we talked about these again in November and naturally they went into place firstly of this 12 months. So, a bit bit of fine information there with the conversion issue. It included the two.5% improve that had been mandated by Congress. It additionally included a .75% improve for clinicians in superior APMs or a
.25% improve for clinicians who take part in MIPS or who’re exempt. After which there was additionally a .49 finances neutrality improve.
Kevin Chmura
So, so the actual affect varies by payer combine, web site of service and high quality of participation. What about RVU associated adjustments?
Robyn Johns
In order that’s form of the satan within the particulars there. It additionally applied a -2.5% effectivity adjustment on sure non-time based mostly providers to the doctor work RVU and there’s additionally a + or -50% follow expense RVU adjustment for facility based mostly providers. So, it’s -50% if it’s facility based mostly providers or a +50% for non-facility based mostly providers.
Kevin Chmura
Wow. So web site of service is more and more strategic and it’s the place we see compliance points typically come up, proper? You get inconsistent documentation, coding and coverage adoptions throughout totally different departments and places. Definitely not simple.
Robyn Johns
No. One thing you positively want to look at intently as a result of it’s totally different relying on the place you’re and what providers you’re offering.
Kevin Chmura
Yeah. So, one different hotspot or one other hotspot that that we frequently see is incident to. What’s happening there?
Robyn Johns
So the doctor payment schedule in that they up to date the definition of direct supervision for incident to billing to completely enable supervision by real-time audio video communication apart from providers which have a ten or a 90-day international surgical procedure interval. So, the supervising doctor now not must be bodily current within the workplace suite, they simply must be instantly accessible by actual time audio video communication.
Kevin Chmura
OK, in order that’s operationally fairly vital, proper? However I assume the compliance take away is comparatively easy. In case you’re utilizing distant supervision, your incident to workflows should be exact. I assume who supervises, the way it’s documented, and the place the exceptions apply as exact as you can also make all of these, huh?
Robyn Johns
Sure, completely. Since you are counting on distant supervision, you’ll wish to guarantee that that’s documented very successfully.
Kevin Chmura
Yeah, cool. So, what concerning the OPPS and ASC ultimate rule highlights for 2026?
Robyn Johns
Yeah. For those who these apply to, there was a 2.6% improve as nicely within the cost charges. In addition they expanded hospital value transparency necessities and we’re seeing much more consideration and possibly enforcement in that as nicely. There was a three-year part out of the inpatient solely listing. Web site impartial funds had been expanded to incorporate Drug Administration Providers and the ASC lined procedures listing is expanded a lot in relation to the inpatient solely listing Part out.
Kevin Chmura
Yeah, that that that that’s an attention-grabbing one. So the part out of the inpatient solely listing is an actual operational shift and it’s a type of alternatives for suppliers to maneuver quantity to raised value places, however actually your compliance must comply with these sufferers, proper and the place you’re having them. And so, when your quantity strikes, audits and schooling have to maneuver with it, which might be a problem and what we all know and we at our guardian firm, at Panacea, value transparency simply stays a compliance and reputational precedence as a result of failures result in penalties, however unhealthy information additionally results in numerous scrutiny. So, good that there’s some, you recognize some steering there, however it’s clear that these are going to be issues that actually have to be paid consideration to from a compliance perspective.
Robyn Johns
Sure, for certain.
Kevin Chmura
So it was arduous to look at the information over the past, I don’t know, six to 12 months with out speaking concerning the One Massive Stunning Invoice Act. So, we’ve been monitoring it. I do know you’ve been monitoring it. So, what’s the timing on follow impacts that you simply count on?
Robyn Johns
So most of these One Massive Stunning Invoice Act Medicaid necessities which are prone to affect practices, they don’t really start till January of 2027. So, practices nonetheless have a while to proceed their evaluation and preparation for these. The immigrant eligibility adjustments do take impact on October 1st of this 12 months, 2026. In order that’s a bit bit shorter time period, however you do have a bit little bit of time to proceed to determine how that will have an effect on your follow in case you have a excessive variety of Medicaid sufferers, and put together for the methods which you could offset these eligibility adjustments and cost necessities.
Kevin Chmura
Yeah, that readability on the efficient dates actually will help groups allocate assets accurately and that’s typically a problem particularly while you’re monitoring proposed guidelines versus ultimate guidelines and unsure when issues will go into impact. In order that’s good. So, as you’re looking on the panorama in 2026, what are a few of your high compliance priorities that you simply’re advising organizations to give attention to?
Robyn Johns
Yeah, we’re at the moment targeted on in all probability 5 or so high priorities for 2026, not in any particular order, however we’re watching information privateness and safety. A part of that’s as a result of HIPAA updates are underway to each the privateness and safety guidelines, although timelines are unclear. We’re unsure when or i f we’ll see any ultimate guidelines on these, however we do know that healthcare stays a major goal of cyber-attacks, so now we have to always be vigilant to that and associated to that, but additionally individually, is AI and different rising applied sciences.
AI is altering the panorama for the varieties of assaults we obtain, but additionally the best way now we have to reply to them. It is also altering the panorama of healthcare typically, each within the supplier workplace and on the payers and on the authorities. These different rising applied sciences like digital instruments, these can improve the compliance danger in your surroundings, and we have to keep in mind that each authorities and industrial payers are utilizing AI to establish outlier claims sooner and improve their auditing.
Then we even have the fraud, waste and abuse enforcement. CMS we all know has at the moment been targeted rather a lot on Medicare Benefit, however that scrutiny can shift oversight over to suppliers as nicely as a result of that’s the place a lot of the information that the Medicare Benefit plans use comes from. The OID additionally continues to give attention to telehealth. There are different focuses are drug system and biologics and program integrity areas akin to DME, Hospice and Drug Administration. So, wish to just be sure you’re watching all of these if you happen to follow there.
Fourth one now we have is vendor and third-party oversight. Most of the largest breaches which have we’ve seen have originated with third events. So, organizations actually need to just be sure you have cautious oversight and keep good monitoring in your third-party distributors and others who could have entry to your techniques and information.
And at last, we all know we’re going to proceed to see these fast regulatory updates. Federal and state adjustments typically battle. We have now numerous states which are at the moment of their legislative interval. So that may carry out some adjustments. After which along with that, industrial payers are tightening their insurance policies and auditing in response to the pressures which are being placed on that on them, whether or not from the federal government or simply from a monetary perspective.
Kevin Chmura
Yeah, it’s one thing the tempo of acceleration of a few of the advances in know-how and the way they how they’re going to affect us. However I assume you recognize that’s actually the truth of 2026 and past. You’re going to see an uptick in in in pace to coverage adjustments, sooner detection, which can be one thing and possibly extra third-party publicity as we depend on increasingly distributors and others to assist us do what we have to do day-after-day, however I’m certain you recognize the recommendation I’ve heard you give many instances and now we have to agree with it. A powerful compliance program must be constructed to adapt. Meaning clear governance, repeatable monitoring and focused auditing tied to the present danger with an eye fixed on the long run and the place all the pieces’s going.
Robyn Johns
Yeah, positively. It’s an thrilling time, numerous alternatives for bettering our packages and actually tightening issues as much as guarantee that we’re defending ourselves and all the knowledge that we’re chargeable for.
Kevin Chmura
Yeah, nice. So, Robyn, thanks for the replace and for serving to our listeners translate coverage motion into sensible compliance actions. To everybody listening, if you need the total context and deeper dialogue, you possibly can entry the webinar on demand at 1st Healthcare Compliance’s web site. It’s referred to as Compliance Cliffs:
Navigating Telehealth Waivers and Reimbursement Adjustments.
Thanks for listening to 1st Speak Compliance and we’ll see you subsequent time. Thanks, Robyn.
Robyn Johns
Thanks, Kevin.
