Medicare 2026: Final Rule, Claim Fixes, and Year-End Reminders

As 2025 winds down, Mary Pat Johnson and Rebecca Greenlaw unpack Humana’s claims reversal and the upcoming MIPS review deadline. They also clarify Medicare participation and opt-out options for ophthalmologists. Tune in for practical insight to keep your practice compliant and prepared for the new year!

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Transcript

Welcome to Ophthalmology Reimbursed, the podcast that discusses all things coding, reimbursement, auditing, and education for the ophthalmic community. 

Hello everyone, welcome back. My name is Mary Pat Johnson.

And I'm Rebecca Greenlaw. Thanks for joining us for this podcast. As we're nearing the end of 2025, there have been a few things we wanted to bring to your attention 

Yeah, so most of you may know that late Friday afternoon on October 31st, CMS released the final rule for the 2026 Medicare Physician Fee Schedule. Yeah, did you notice they dropped that about 5.10 on Halloween afternoon? Yeah, trick or treat. And it's a mixed bag of tricks and treats.

Yeah, for sure. We'll have more on that in our What's New in 2026 webinar. Yeah, I'm happy to have the information.

So now we can finalize those slides. That's going to be a good program. Aside from that, Rebecca, do you mind talking a little bit about that claims issue we had with Humana? I know we discussed it when we had a quick podcast from the Academy.

But if you don't mind sharing the update, I think that's pertinent here since they've made some moves. Yeah, so I don't think everybody needs a reminder that Humana was denying office visit, E&M and I-Codes when testing was done the same day. Humana has reached back out to the Academy saying that they have suspended this claim denial indefinitely.

It was effective October 30th. Humana put a stopgag on its claims processing system to prevent further denials. They did say that it is possible for some denials to still slip through even though the stopgag was put in place.

Humana will automatically identify and reprocess all of the impacted claims for ophthalmologists. So practices, there's nothing for practices to do to resolve their previously denied claims. The Academy said that they are working with Cigna and Molina Health to resolve similar issues, although we've not heard anything back from Cigna or Molina yet.

And then the Academy says that if you're still receiving denials from Humana in November, reach out to them at healthpolicyataao.org. And just to refresh my memory, these are the denials for offices billed in addition to diagnostic testing and the instruction they gave us to add that modifier 25, correct? Correct. That is the one. Okay.

And the timing couldn't be worse, but Medicare had kind of a glitch with an edit October 1st as well. People were seeing denials with nine, let me think about this, 92014, the IECA exam code with the new 92137. And Medicare has admitted that's an erroneous bundle and they intend to fix that.

They have not been bundled the first three quarters of the year. So I'm not sure how that happened, but just a few people have reached out. Medicare did say they're going to look into that one though.

Excellent. Excellent. Okay.

Moving right along again, because it's year end and we're looking at 2026, I wanted to point out if no one saw it, or if you looked at it quickly, the ASCRS and ASOA publishes a Washington Watch email periodically. And this week they mentioned that the 2024 MIPS scores are out. And of course that means it's going to impact your 2026 reimbursement.

The only reason I wanted to bring it up here is because there is a really rapidly approaching deadline, less than two weeks that we need to be aware of. So just to recap what the Washington Watch article said, again, the scores have been published. You can view your score on the QPP website.

As in the past, you'll use your HARP system credentials to get that. Remember that the size of your adjustment, both up or down, depends not only on how you performed, but also on the distribution of scores for everyone else who participated. So because of this, we're taking everyone else's scores into consideration.

The bonus for the same MIPS score year over year could lead to a different bonus payment. Does that make sense? So you have the same score and yet your outcome could vary. So here's the deadline I want you to be aware of.

If you believe there's been an error in how your MIPS score was calculated, you're allowed to submit for a targeted review. And that targeted review request has to be in by 8 p.m. Eastern time on November 14th. So that means if you intend to submit one, submit that now.

Again, you'll- And that's an important deadline. It is. And the QPP website, again, is where I think you're going to, or where they've instructed us to go to complete that review request form.

Great. Another topic, a question that I've not heard in a while. It's come up several times and it has to do with physicians changing their participation status.

Have you been hearing anything on that? You know, I've gotten just a few calls, but like you, I haven't heard this one in a while. So it's kind of surprising that a few have come in. And now that I'm thinking about it, they've come in from practices that have recently changed ownership.

So maybe that's why we've got new people in place or as an ownership or as an entity, they've decided to make a change. Yeah, that's interesting. I was thinking maybe it had to do something with staff turnover and the current staff not knowing anything about it.

Could be. You know, it's kind of interesting too. One of the questions that I get makes me think there's a big misunderstanding, I guess is the best word, for the difference between being a non-participating provider and not being an enrolled provider at all.

So I'm getting calls from people who sound like they believe non-PAR means they're outside the Medicare program, which of course is not what that means at all. So there are really three options. If you decide to participate, decide to enroll, you have the option to participate or not participate.

And then of course you have the option to not enroll, which kind of takes you out of the Medicare world altogether. Right. And for doctors who are currently enrolled in Medicare and they want to opt out, they have to obtain and complete an affidavit that can be found on the MAC website and return that to Medicare.

Right. So if you've never enrolled in Medicare or were previously enrolled as a non-participating provider, the opt-out period starts the date you sign the opt-out affidavit. If you're previously participating, your opt-out period starts the first day of the next calendar quarter.

That's if the affidavit was submitted at least 30 days before the start of the quarter. Yeah. And remember being opting out means you do not submit a claim to Medicare.

You're not bound by the Medicare allowed amounts, their coverage policies. The patient may not submit a claim to Medicare. So we don't really see this a lot in ophthalmology.

Ophthalmology practices rely heavily on Medicare-aged patients. We've only seen, I've been doing this a long time, we've only seen a few practices say we don't want to be involved with Medicare at all. One was pediatrics and a couple were refractive surgery back in the days when LASIK was, you know, so popular and keeping practices busy.

So the opt-out status doesn't really have much impact in ophthalmology. So once you decide to participate or to enroll, I should say, I too am confusing those words, and to enroll in Medicare as an enrolled Medicare provider, now you have to make that distinction of being participating or non-participating. Quick summary of the differences.

A participating provider follows all the Medicare rules, coverage rules, et cetera, is obliged to accept the allowed amount as payment in full, must submit claims on behalf of the patient. A non-participating provider can choose which patients they're going to accept assignment on. So some of their claims may go out looking much like a participating provider.

They accept assignment, they're subject to the allowed amount, et cetera. But for the claims they decide to not accept assignment and as a non-participating provider, they get to make that choice. If you submit a non-participating claim, Medicare will pay you less.

Well, let me back up. First, you still have to submit. Being non-part does not get you out of the claim submission piece.

So you'll submit, the payment will go to the patient, and then you have to collect from the patient. Medicare pays you 5% less than they would have paid a participating provider. But you collect from the patient up to what Medicare calls their limiting charge.

And it's about 9% more than the published fee schedule for a participating doctor. So let me just go through a couple of quick examples. If you build a comprehensive new patient eye exam, 92004, as a participating provider or as an assigned claim, the allowed amount for that's about $143.

Rounded numbers, it's 143. Medicare pays 80%, patient pays the balance of 20%. But you may not collect more than the exact number, 142.97. Now, if you're submitting a non-assigned claim, if you're a non-participating provider and opt for a non-assigned claim, Medicare drops their payment by 5%.

So you get about 136 from Medicare. You're not capped at that $143 allowed amount, you get to go up to the limiting charge, which in this case is $156. So there's more revenue to the practice to be non-participating and submit a non, excuse me, yeah, non-participating and submit a non-assigned claim.

But there's additional work because the money's going to the patient. So if you decide to take that route, and 9% is a big number, it sounds very attractive, but you really have to have good systems in place for patients to pay their bill at date of service. Because we have seen patients get the check from Medicare, cash it and spend it, and still the doctor's left unpaid.

So you've got to have strong personalities who are willing to look at the patient and say, yes, I need the money today, not fall for all the reasons why they say they can't pay, and good processes in place to follow up if you are allowing them to make payments. So checkout staff here is very important. Yeah, very important.

Now, the decision to be a participating physician or a non-participating physician is up, of course, to the doctor. It's a decision they get to make once a year. So if you're first enrolling in Medicare for your very first relationship, you would complete the CMS 855i form.

And again, that's going to be on your MAC's website. If, as we move into 2026, you want to leave your status exactly as it was, do nothing. Medicare is just going to roll it over, and you will be participating in 26 if you're currently participating, and you'll be non-par if you're currently non-par.

If you do want to change your status, depends on the direction you're going. If you're going from a non-participating doctor to a participating provider, you'll complete the Medicare Participation Physician or Supplier Agreement. I think that's CMS 460. 

Again, it's on the CMS website. That must be postmarked by end of year, so 12-31-25. If you're going the other direction, you're currently a participating provider and want to enroll as a non-participating provider, now you have to write to every MAC that you've sent Part B claims to, telling them that you no longer want to participate.

So, if you live near a state line and you've got patients coming in, or you have offices in multiple states, then there might be different MACs included. Be sure to reach out to each of those MACs. Again, the deadline here is December 31st.

So, you'd want to make your effective date January 1st of 2026. Yeah, correct. Yeah, and we talked earlier about the idea of opting out of Medicare.

If you decide to opt out of Medicare, that's for a minimum of two years. And at that two-year mark, unless you tell them, they're going to re-up you again as a non, they're going to leave you opted out. So, if you want to get back in the Medicare program down the road, that then would take an action on your behalf.

Excellent points. The rest of what we're seeing for the new year seems to be fairly calm. We don't have a lot of new ICD-10 codes.

We have one, from what I can find, one new CPT code. And we're looking through regulatory and policy updates to make sure we provide all that information to you. But that's coming later in the year, starting the first week of December with our What's New for 2026 webinar.

And actually this year it's titled What's New for 2026 and How Are We Going to Handle It. So, we're trying to give you a few possible solutions to some of the changes that are being made. So, that's it.

I know you're busy. We won't keep you any longer, but thank you again for joining us. Just want to say, you know, look out for another edition of Ophthalmology Reimbursed in the next few weeks.

Of course, if you have any questions, feel free to reach out to us, 1-800-399-6565. We'll be happy to go over any questions that you have with you. All right.

Stay well, everyone. 

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