Medicare visits conducted via telehealth skyrocketed from roughly 840,000 in 2019 to a staggering 52.7 million in 2020, according to the Department of Health and Human Services—and that shift isn’t reversing. As healthcare evolves, payers face a wave of changes impacting reimbursement and fraud prevention, with new rules around telehealth, remote monitoring, skin substitutes, and durable medical equipment.
Here are three key areas for payment integrity teams to watch as the new year unfolds.
Telehealth & Remote Monitoring: Access Expands, Risks Rise
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Telehealth has moved beyond a pandemic stopgap and is now a core part of Medicare, with relaxed frequency limits for virtual consultations in inpatient, nursing, and critical care settings. The Centers for Medicare & Medicaid Services (CMS) now considers many telehealth services permanent, unifying codes and allowing direct supervision via real-time audio-video. Behavioral telehealth has also expanded with new codes for psychiatric care, group counseling, and digital mental health tools. Audio-only telehealth remains an option for behavioral health, provided providers document why video isn’t feasible using Modifier 93.
This increased access comes with increased risk. Payers need to monitor for documentation gaps, coding errors, and potential abuse—like excessively long 60-minute sessions, overlapping appointments, and systematic upcoding. Claim data indicates a noticeable increase in 60-minute behavioral telehealth sessions in recent years, coupled with a decrease in 45-minute sessions, as shown in Figure 1.
Remote patient monitoring (RPM) is also expanding rapidly. Approximately 4,600 medical practices routinely billed for RPM in 2024, with about five new practices joining each month, according to the HHS Office of Inspector General (OIG). CMS is introducing new codes for shorter monitoring periods (2–15 days) and reduced clinician interaction (10 minutes), supporting acute-episode monitoring.
However, this growth creates opportunities for abuse. Common schemes include billing for multiple devices per member monthly, rapid increases in member billing, and billing for a high volume of members with no prior practice history. Payers should require proof of a provider-patient relationship before device deployment and establish clear standards for interactive communication—favoring real-time audio/video over text messaging.
Skin Substitutes: A Reimbursement Overhaul
CMS is enacting a major payment reform by shifting skin substitute reimbursement from product-specific rates to a standardized “incident-to” supply model. This aims to eliminate financial incentives driving overutilization of expensive biological products. Most skin substitutes will now be grouped by FDA regulatory pathway—Pre-Market Approval (PMA), 510(k) devices, and Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/P)—and paid a uniform rate of approximately $127.28 per square centimeter. CMS projects this will reduce Medicare costs for skin substitutes by nearly 90%.
While this policy can curb FWA, providers may attempt to circumvent it by inflating quantities or substituting products within categories to offset revenue losses. Payers should strengthen oversight by monitoring utilization trends and validating documentation for clinical necessity.
DMEPOS: Streamlining & Increased Scrutiny
For durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), CMS will relaunch the competitive bidding program in 2026, adding a Remote Item Delivery track for high-volume items like continuous glucose monitors and insulin pumps. Accreditation requirements will tighten with annual surveys and greater transparency from accrediting organizations, including mandated unannounced surveys to align with federal standards.
CMS will also exempt suppliers with a 90% claim approval rate from prior authorization, reducing administrative burdens—but potentially creating new vulnerabilities that require careful monitoring.
Next Steps for Payers
These changes aren’t incremental; they represent a fundamental shift in care delivery and reimbursement. For payers, this means moving beyond awareness to decisive action. The complexity of telehealth, RPM, and the new reimbursement models for skin substitutes and DMEPOS demands a proactive, coordinated approach.
| ASAP | Next 90 days | Next 90–365 days |
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These 2026 regulatory changes represent a paradigm shift in care delivery and reimbursement. While these updates promise improved access and efficiency, they also demand heightened vigilance. By implementing robust monitoring strategies, leveraging advanced analytics, and fostering cross-functional collaboration, payers can mitigate risks and protect payment integrity while safeguarding their members’ benefits.
Dive deeper and stay ahead of potential FWA patterns that may arise in 2026. Don’t miss our latest on-demand Payment Integrity Pulse webinar as we discuss key regulatory changes and the trending schemes found in data that may be affected by these actions.
Krista Baisch, J.D., vice president and associate general counsel, also contributed to this article.
