What CMS did
On July 14, CMS released the CY 2027 Physician Fee Schedule proposed rule. Buried under the conversion factor math is a provision aimed directly at the remote patient monitoring industry. CMS proposes to pay for RPM and RTM services only "when performed by clinical staff employed by the practice and not when those services are delivered by contractors." Add a required initiating visit before monitoring starts, and a requirement that remote therapeutic monitoring go only to established patients, and the message to third-party RPM vendors is hard to miss. As I read it: you are not proximal enough to the ordering physician to keep getting paid. The full text is here; comments close September 14.
Nine days before the rule dropped, CMMI's ACCESS Model (Advancing Chronic Care with Effective, Scalable Solutions) went live: a ten-year test that pays a recurring, per-patient amount for technology-supported chronic condition management, with full payment contingent on hitting an outcome target, like lowering a patient's blood pressure 15 mmHg from baseline.
CMS does not say the two are connected. But taken together, my read is straightforward: CMS is pushing reimbursement for remote patient monitoring out of fee-for-service and toward an outcomes-based framework.
The spirit is just
In my travels with different ACOs and risk-bearing providers, there is, unfortunately, a lot of low-value RPM out there, delivered because it's an advantageous revenue stream rather than because anyone expects it to bend a patient's trajectory. The numbers back the impression. Medicare enrollees receiving RPM grew more than tenfold from 2019 to 2022, and OIG found that 43 percent of them weren't receiving all three components of the service. Payments hit $536 million in 2024, up 31 percent in a year, and one of the billing patterns OIG now flags for scrutiny is practices billing monitoring for large shares of patients who have no prior history with the practice. That last one is the tell. A lot of RPM work is being done on patients outside the general infrastructure a practice has set up to manage population health and costs, which is to say it is divorced from cost. A Health Affairs analysis of 754 practices that adopted RPM found Medicare revenue rose roughly 20 percent relative to similar non-adopters, while outpatient visits went up, not down.
Some history is useful here. Before the RPM and CCM codes were created, providers rued the inability to monitor their patients more closely, because the extra work was free. So CMS built the codes. And if we are being honest about what happened next, billing them has become as universally valuable to patients as "making sure patient conditions are accurately documented" is universally valuable to patients. Which is to say, much of it is a cash grab.
The distance problem
Here is the defense of the practices, and it's real. For a lot of practices, integrating remote monitoring or care management into the workflow is very hard. There simply isn't the staffing to do it. A decade in, chronic care management is still billed by a small minority of clinicians, and when researchers ask practices why, the answer is consistently staffing and workflow. Outsourcing was the rational response.
But CMS's instinct is correct. The value of this work is lower the further it gets from the doctor-patient relationship. Medicare beneficiaries whose care sits with a physician who knows them run 7 to 10 percent lower total spend with fewer hospitalizations and ED visits, a finding that has held up for years. An individual-patient meta-analysis of 25 blood pressure self-monitoring trials makes the point clearly: monitoring alone has limited value. Monitoring embedded in an active clinical workflow, particularly one that supports medication adjustment, can produce materially larger blood-pressure reductions. Heart failure telemonitoring run as a centralized service apart from the patient's own clinicians did not reduce readmissions in BEAT-HF. Run as a physician-staffed center wired into the patient's local care team, it cut days lost to hospitalization and death in TIM-HF2. The cuff is not the intervention. The physician acting on the cuff is the intervention.
Where the real value is
There is real value in providing extra digital monitoring for some patients with remotely monitorable chronic conditions, provided two things are true: the patients selected are the ones most likely to benefit, and the supervising physician uses this extra patient support as part of a comprehensive effort to manage the costs of their population. That is not most RPM today. It is what RPM should have been all along: a clinical tool pointed at the patients where monitoring changes what happens next, run by a practice that is accountable for what happens next.
The ACCESS gap
Which brings us to the problem: ACCESS is not built for that population. To be fair, the model is clinician-guided: it requires a physician clinical director, and it pays referring clinicians for reviewing monitoring data and making changes like medication adjustments. But the economics appear designed for scalable ambulatory disease management of defined conditions. The early cardio-kidney-metabolic track covers hypertension, dyslipidemia, obesity, and prediabetes; heart failure is not a named qualifying condition in the initial tracks. The initial participant list is heavy on device makers and digital therapeutics companies, and the payment is a quarterly amount that pays in full when a number moves. For that tier of patient, fine.
Nothing about the payment looks sized for the intensive, clinician-heavy monitoring an unstable Class IV heart failure patient requires. For that patient, who is going to bounce in and out of the hospital without well-monitored RPM, ACCESS is not nearly enough money to justify the resources needed to meaningfully divert that trajectory. Yet paradoxically, that is exactly the patient who needs it. TIM-HF2 is proof the intensive version works. It is also proof of what it costs: a 24/7 physician-staffed monitoring center integrated with local clinicians. There is a gap in the outcomes models right now, and the highly vulnerable patients most likely to benefit from RPM are sitting in it.
A shot across the bow
So I would read the proposed rule as follows: it is a shot across the bow. CMS has a pattern of holding its policy direction while softening operationally rigid rules. Take split/shared E/M visits: CMS set out to require that the billing practitioner be determined strictly by time, delayed the requirement year after year under provider pushback, and ultimately allowed either time or the substantive portion of medical decision making. The direction, that billing should follow the clinician actually doing the work, survived. The rigid implementation did not. And when a rule proves unworkable enough, CMS will drop it entirely, as it finally did with the imaging appropriate use criteria program in 2024. So call this a prediction, and an uncertain one: the employee-only provision could go through unchanged, but I would be surprised if CMS retains it in its current form. The language may soften; the proposal itself asks commenters about third-party billing and its effects on access, which suggests CMS recognizes the provision could be disruptive. Even if it does soften, I expect the broader direction to hold: tighter integration with the treating practice, less tolerance for arm's-length vendor models, and greater accountability for outcomes. In this same proposed rule, CMS revives a same-day E/M payment cut it shelved in 2019, noting that it "did not finalize the proposal at that time" while still believing it is paying twice for the same work. CMS retreats. Then CMS returns.
And the direction of travel shows up in where this rule adds money: a proposed 32 percent E/M add-on for practitioners in Shared Savings and LEAD ACOs providing longitudinal care, and a comment solicitation on prospective primary care payment inside MSSP. CMS is signaling concern about an RPM market that has too often been organized around billable activity rather than integrated clinical care. Dollars are moving toward accountable, longitudinal relationships. And in my experience, RPM is often considered more as a revenue opportunity than as an outcomes driver, right alongside CoolSculpting in a broader portfolio of revenue augmentation strategies.
What comes next
It is not yet clear whether CMS will take a vendor-focused or a practice-focused approach to outcomes-based RPM. I would not be surprised to see CMS do for remote monitoring what GUIDE did for dementia: a condition-specific, longitudinal payment with accountability built in, where an enhanced care coordination payment serves as an advance on shared savings. Alongside it — and this will not please the RPM industry — expect meaningfully narrower eligibility criteria for the service itself.
If you bear risk, the move is not to wait for the final rule. Pick the patients where monitoring actually changes trajectory, put a physician's judgment in the loop, and count the program's value in total cost of care rather than code volume. That is where CMS is headed, whatever survives into the final rule this fall.