Business Coaching for Healthcare Providers

Dear Colleagues,

The landscape of specialist reimbursement is undergoing its most significant transformation in decades. As your partners in this transition, we at LexCare Partners want to ensure you are informed, prepared, and positioned to thrive under these new payment models. The changes below are not proposals,  they are finalized rules and programs that are either already in effect or launching imminently.

The 2026 Medicare Physician Fee Schedule (PFS) final rule took effect January 1, 2026, and it introduced one of the most consequential payment changes in recent memory: two separate conversion factors based on whether you participate in a qualifying Alternative Payment Model (APM).

• APM Qualifying Participants receive a conversion factor of $33.5675 — a 3.77% increase from 2025. Non-qualifying participants receive $33.4009 — a 3.26% increase. The differential is codified in law and grows each year.
• Physicians in Qualifying APMs also receive a 3.5% bonus on Medicare payments and are exempt from MIPS reporting entirely.
• The 2026 PFS also introduced new Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) codes, and increased the average national reimbursement for Chronic Care Management (CCM) code 99490 to $66.13 — a 9% increase over 2025.
• MIPS performance thresholds for 2026 are set at 75 points, with payment adjustments of up to ±9% based on performance across Quality (30%), Cost (30%), Improvement Activities (15%), and Promoting Interoperability (25%).

The financial advantage for joining a risk-based arrangement has never been more concrete or immediate.

On July 5, 2026, the ACCESS Model — Advancing Chronic Care with Effective, Scalable Solutions — officially launched. This is no longer a future opportunity. It is open now.

This 10-year voluntary program does something no major Medicare initiative has done before: it pays providers based on whether patients actually get healthier after receiving care.

Key facts you need to know right now:

• The ACCESS Model introduces a recurring Outcome-Aligned Payment (OAP) approach that pays for measurable health outcomes through technology-enabled care, without requiring providers to follow a specific care model.
• Four clinical tracks are available: Early Cardio-Kidney-Metabolic (hypertension, dyslipidemia, obesity, prediabetes); Cardio-Kidney-Metabolic (diabetes, chronic kidney disease, heart disease); Chronic Pain; and Depression.
• More than 150 organizations — including major technology companies and medical practices — have already been accepted to participate at launch.
• Rolling start dates continue through 2026, with additional cohorts beginning August 17 and October 1, giving practices that missed the July launch continued opportunities to join.
• A second cohort begins January 1, 2027 — so the window to join remains open, but preparation time is shrinking.

As CMS Administrator Dr. Mehmet Oz stated at the program's announcement: "The technology to transform care is available today. However, a payment mechanism that supports technology-enabled care and the outcomes they achieve is needed. The ACCESS Model fills that gap."

The Ambulatory Specialty Model (ASM) is a mandatory, five-year program running from January 1, 2027 through December 31, 2031, targeting specialists who treat heart failure and low back pain. This is the watershed moment for specialist reimbursement.

What makes ASM different from every previous CMS model:

• No opt-out. Clinicians meeting ASM criteria within selected geographic markets are automatically included, with no opt-out or hardship exemption pathway.
• CMS projects approximately 8,600 physicians in selected geographies — roughly one-quarter of all core-based statistical areas — will be required to participate, managing roughly 600,000 heart failure and low back pain episodes per year for approximately 550,000 beneficiaries and approximately $2.8 billion in episode spending annually.
• Cardiologists in designated regions with sufficient heart failure volume will be automatically included based on historical Medicare claims data.
• CMS is also proposing to score quality measure MIPS Q492 — Risk-Standardized Acute Unplanned Cardiovascular-Related Admission Rates — at the individual TIN/NPI level beginning in 2027, meaning personal accountability is unavoidable.
• ASM is not designated as an Advanced APM under MACRA and therefore does not qualify participants for the 5% APM incentive bonus.

Important update as of August 2026: CMS has proposed several changes and clarifications to ASM in the 2027 Medicare Physician Fee Schedule proposed rule, published July 14, 2026. Comments were due September 14, 2026. The proposed updates include exception processes for certain heart failure subspecialty redesignations, allowing multiple ASM participants billing under the same TIN to participate in a single collaborative care agreement (CCA), and other measures intended to reduce administrative burden. The final rule is expected by November 2026.

Payment adjustments tied to ASM performance begin in 2029, ranging from -9% to +9% of Medicare Part B claims, scaling up to ±12% by 2033.

Performance is measured over five years, meaning operational gaps in monitoring, documentation, and care coordination can compound over time. Every decision you make starting January 1, 2027 is being scored.

ASM holds selected specialists financially accountable for longitudinal management of heart failure and low back pain. Payment adjustments are based on performance across quality, cost, care improvement activities, and interoperability — combined into a composite score that directly influences future reimbursement.

Over time, CMS plans to expand ASM participation to include additional ambulatory specialties such as gastroenterology, neurology, and pulmonology, particularly those with high outpatient volumes and predictable care patterns. If your specialty is not on the mandatory list today, it may be soon.

CMS will use funds withheld from participating physicians' claims to fund bonuses for high-performing ASM physicians. The model is not budget-neutral — CMS will retain 15% of withheld funds to ensure savings for the Part B trust fund.

ACCESS complements traditional care and does not require providers to follow a specific care model. Care can be delivered in-person, virtually, asynchronously, or through other technology-enabled methods.

Participation is optional and the program is planned to last 10 years. More than 150 organizations have already signed up, including technology companies and medical practices. The first mover advantage is real — organizations already enrolled are building the outcome data, patient relationships, and technology infrastructure that late entrants will spend years trying to replicate.

These changes require immediate attention in three critical areas:

Technology and Data Infrastructure
Success in value-based care depends on your ability to capture, analyze, and act on performance data. For heart failure practices, sustained disease stability, hospitalization prevention, and reliable physiologic measurement will directly influence financial outcomes under ASM. Without robust analytics, managing financial risk or optimizing performance is not possible.

Financial Risk Management
The actual impact for any individual physician or group depends on their specific CPT code mix, the proportion of work delivered in facility versus non-facility settings, and whether they participate in a qualifying APM. You need personalized financial modeling — not industry averages.

Clinical and Operational Workflow
Early planning, contracting updates, and alignment with primary care partners are essential to succeed under ASM's new value-based payment structure. Staff roles will evolve, documentation requirements will change, and collaboration across specialties becomes a financial imperative — not just a clinical best practice.

Navigating this transition alone is neither necessary nor advisable. The regulatory complexity, financial implications, and operational challenges are substantial. This is where LexCare Partners makes the critical difference.

We specialize in guiding healthcare practices through value-based care transitions. Our services include:

Strategic Planning — We help you evaluate which models apply to your specialty and practice size, determine whether mandatory ASM participation affects you, assess ACCESS Model eligibility and readiness, and develop a customized roadmap for participation.

Financial Modeling — We analyze your current revenue streams and project the financial impact of various value-based arrangements — including the concrete difference between qualifying and non-qualifying APM conversion factors under the 2026 PFS — so you understand both your risks and your upside.

Technology Selection and Implementation — We guide you toward the data and analytics tools you need, avoiding costly mistakes and ensuring systems integrate with your existing workflows and meet CMS interoperability requirements.

Performance Optimization — Once you are participating in a model, we help you track metrics, identify improvement opportunities, and maximize performance-based payments. Under ASM, every data point from 2027 forward affects your 2029 payment.

Regulatory Compliance — We keep you current on changing requirements — including the evolving ASM proposed rule updates and final rulemaking expected by November 2026 — and ensure you meet all reporting and quality obligations.

The ACCESS Model is live. ASM mandatory participation begins January 1, 2027 — less than four months away. The 2027 Medicare Physician Fee Schedule proposed rule is in comment period now, with a final rule expected in November 2026.

This is not a future problem. It is a present one.

Specialists who prepare now will enter 2027 with documented workflows, data systems, and compliance infrastructure in place. Those who wait will begin the five-year ASM performance clock behind — and that gap compounds.

We invite you to schedule a consultation with LexCare Partners to discuss your specific situation. Whether you are a solo practitioner or part of a large group, whether your specialty faces mandatory ASM participation or you are evaluating the ACCESS Model, we are here to help you navigate these changes with confidence.

Let's have a conversation about what this transition means for you and your practice.

We are here to help you turn these challenges into opportunities.

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LexCare Partners provides compliance education, business coaching, and consulting services for healthcare organizations. We do not provide legal advice. Providers should consult with licensed legal counsel for jurisdiction-specific guidance.