Bobbi Buell's Newsletter

Roberta L. Buell is a Principal at onPoint Oncology Inc., specializing in oncology reimbursement. With over 23 years of experience in billing, coding, and drug therapy reimbursement, she's a nationally recognized expert and frequent speaker on regulatory and reimbursement issues. Bobbi has led more than 600 seminars since 1991 and currently serves as content director for focalPoint® and assistPoint®. Learn more about Bobbi here .

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Latest issue February 2026

February 2026

OPPS Q1: Better Late Than Never

The Transmittal for First Quarter, 2026 , was delayed almost a month. What? At this point, we can say this transmittal is action-packed and important. I would guess that is why the MACs had to scramble in the first month of 2026. Anyway, check it out — some really useful content. ASP Changes from the Final Rule Effective January 1, 2026, payment rates for many drugs and biologicals have changed from the values published in the CY 2026 OPPS/ASC final rule due to new ASP calculations based on sales price submissions from the third quarter of CY 2025. In cases where adjustments to payment rates are necessary, they will be incorporated into the January 2026 Fiscal Intermediary Standard System (FISS) release. CMS is not publishing the updated payment rates in this Change Request; it is implementing the January 2026 OPPS update. However, the updated payment rates, effective January 1, 2026, can be found in the January 2026 update to the OPPS Addenda A and B on the CMS website.…

February 2026

Medicare Advantage & Part D Proposed Rule 2027

The Centers for Medicare and Medicaid Services (CMS) released the Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program. CMS projects that the proposed updates would result in an average net payment increase of 0.09% in 2027, or 2.54% after accounting for expected coding trends. These figures are preliminary and will likely change before the final rate notice is issued on or before April 6, 2026. Just as importantly, the impact will vary widely by plan based on geography, enrollee risk profile, and quality bonus eligibility, underscoring why stakeholders should look beyond the headline number. Comments on this proposed rule were due to CMS by January 26, 2026. But comments may be largely ignored anyway. Medicare Part D Redesign The Inflation Reduction Act of 2022 (IRA) introduced major changes to the Medicare Part D prescription drug benefit and gave CMS temporary authority—through…

February 2026

Telehealth Extended to 12/31/2027 and More!

President Trump on Tuesday signed into law a funding bill that ended a short-term partial government shutdown, funds the Department of Health and Human Services, extends telehealth and virtual care flexibilities, and enacts pharmacy benefit manager reform. What's not to like? See the next paragraph. The minibus package did not revive Affordable Care Act enhanced premium tax credits that expired December 31, 2025. Nor did it include provisions from President Trump's healthcare plan to send money directly to consumers' health savings accounts. The Senate on January 29 voted 71-29 to advance the package, and the House on February 3 voted 217-214 to send the bill to President Trump for his signature. The bill includes the following: Telehealth--There will be a two-year extension of Medicare telehealth flexibilities. This means all provisions in effect before January 31, 2026, are reinstated. The provisions are slated to end December 31, 2027. The bill also requires HHS to issue guidance…

Earlier issues

January 2026

Medicare Wants to Overhaul Claims

How many of you have been through a Medicare or other payer claims adjudication system conversion? A few of them in my lifetime have been ok, while others have been unmitigated disasters, with delays, incorrect claim determinations, and mismatches between policies and claims. This proposed program (it is not a proposed rule) is the blend of FOUR legacy systems written in COBOL (programming from ancient digitheads). Think of a billing system conversion times 100. This is why you should be aware of this NOW before it goes any further. This is a REQUEST FOR INFORMATION--it is not a proposed rule, not a directive, not an executive order. CMS (Claims Might Suck) just wants COMMENTS for now. And, it is a good idea to comment before it's too late. As a spoiler alert, I will posit that there is too much emphasis on fraud and waste. Every administration believes it can pull money out of the air by finding more fraud. Here's a bit about the Request for Information, including objectives and…

January 2026

How's It Going With Prior Auth?

Health insurers pledged in June 2025 to overhaul their processes as part of a Trump administration initiative to reduce the volume of prior authorization requirements and modernize how requests are handled. According to AHIP (Association of Health Insurance Plans), they pledged to the following goals for January 1, 2026 Reducing the Scope of Claims Subject to Prior Authorization. Individual plans have committed to specific reductions to medical prior authorization as appropriate for the local market each plan serves. Ensuring Continuity of Care When Patients Change Plans. When a patient changes insurance companies during a course of treatment, the new plan honors existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period. This action is designed to help patients avoid delays and maintain continuity of care during insurance transitions. Enhancing Communication and Transparency on Determinations. Health plans should provide clear…

January 2026

Two New Drug Demos PROPOSED

On December 23, 2025 (while you were drinking eggnog), CMS published two proposed rules intended to activate the Trump Administration’s stated policy goal of aligning U.S. pharmaceutical pricing with that of other so-called developed countries using “most favored nation” comparisons. The proposed rules— Global Benchmark for Efficient Drug Pricing (“GLOBE”) in the case of Medicare Part B, and Guarding U.S. Medicare Against Rising Drug Costs (“GUARD”) will be managed and fall under the agency’s Innovation Center payment ("CMMI")and service model demonstration and waiver authority. As proposed, the models would test alternative methods for calculating manufacturer rebates under the Medicare Part B and Part D inflation rebate programs by tying applicable pricing benchmarks for model drugs to international pricing information, among other changes. Comments on the proposed rules are due on February 23, 2026 This article explains: a very high-level overview of the proposals, potential…

December 2025

ACCESS Demo: The Future?

For my entire career (and that's a really long stretch), insurers, the government, and medical groups have been trying to figure out how to pay for better outcomes. The problem is that no one really knows how to define 'better'. Here we go again. The Centers for Medicare & Medicaid Services (“CMS”), through the CMS Innovation Center (“CMMI”), has announced the ACCESS Model—Advancing Clinical Care, Equity and System Sustainability , a demonstration model that aims to create an outcomes-based payment pathway for chronic-condition management, care coordination, and health-related social needs (“HRSN”) integration. The ACCESS Model claims to be different from other models. This is because it establishes a structure that allows a wide range of Medicare Part B-enrolled organizations—including physician practices, digital chronic-care platforms, home-based providers, and community-supported care organizations—to receive Medicare payments tied directly to clinical and equity-related…

December 2025

HCPCS Q1 2026

Sometimes when you work in reimbursement, you feel like a total loser. Today, I am feeling that way. As you all know, I do not distribute the new ASPs in this newsletter each quarter. My attorneys do not want me discussing drug margins EVER, and publishing pricing might infer that. A little paranoid--but it is what it is. Anyway, I went into the ASP files , now also known as the Payment Limit Files, and I was shocked (which many of you may not be) that some drugs are being paid at AMP, Average Manufacturers' Price. AMP is generally only used for Medicaid rebates. I suddenly remembered that CMS uses AMP when the Office of Inspector General (OIG aka the Oy General) informs CMS that a product’s ASP is at least 5% higher than its AMP; the ASP for the billing code has exceeded the AMP for the billing code by 5% or more in two consecutive quarters, or three of the previous four quarters immediately preceding the quarter to which the price substitution would be applied. I was just shocked…

December 2025

Get Ready! Get Set for 2026!

Well, the new year is almost upon us!!! To help you during this super-busy time of year, I have a little checklist for you to make sure you haven't forgotten anything before you start imbibing holiday cheer. And here it is: Verify all patient insurance for those in treatment. This year, it is particularly poignant, as many patients on the Exchange (Obamacare) may drop their plans or stop paying premiums in the next year. Also, Medicare patients may be going on or off Medicare Advantage. Get authorizations for each plan and/or patient where authorization must be renewed annually or (God forbid) quarterly. Pre-authorize all drugs, therapies (i.e., Radiation), and other services/procedures with new codes (e.g., RPM, RTM). Make sure insurance covers new codes and services in the new year, or when they are covered in 2026. Update your facility for the new codes you will use in 2026 in your EMR, Patient Accounting System, and pharmacy inventory. Update your charge entry for the new RVUs…

November 2025

Parts C and D Proposed Rule 2027

CMS, on November 19, 2025, released proposed new policies for MA and Medicare Part D prescription drug programs for calendar year 2027. Again, this is just a proposal, and it does not go into effect until January 1, 2027. Also, there will be a Rate-Setting proposal. The 465-page proposed rule, which was published in the Federal Register on November 28, includes significant changes to Star ratings quality measures. The agency uses the measures to rank Medicare Advantage and drug plans. These have been a source of controversy from major health plans such as United and Humana . High-performing plans qualify for coveted quality bonus payments and may use the additional payments to cover the cost of supplemental benefits, reduce cost-sharing, or provide extra benefits not covered by traditional Medicare. Comments are due by January 26, 2026. Among the proposed changes announced in the rule, CMS said it wants to possibly implement these: Streamline Star ratings by removing measures focused…