Medicare 2026 Fee Schedule: 5 Big Opportunities for Providers & Startups

By Alex Yarijanian

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The 2026 Medicare Physician Fee Schedule is packed with updates.
Some are subtle.
Some are seismic.

Today, I’m cutting through the noise and breaking down the five biggest opportunities I see for 2026 — why they matter, and how you can prepare.

1. Remote Monitoring Becomes a Real Business Line

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Remote monitoring is finally getting a modern overhaul.

For years, RPM and RTM rules have been rigid —
“16 days of data or don’t bill at all.”
Time thresholds that didn’t match real clinical workflows.

Starting in 2026, that changes.

You’ll be able to bill for:

• 2–15 days of monitoring

• Reduced time thresholds to 11–20 minutes

• Additional billing in 10-minute increments

Why it matters:
Remote care becomes more billable, more flexible, and more profitable.

Think about:

• Post-op check-ins

• Chronic care touchpoints

• Medication titration

• Brief adherence coaching

Startups should design services around shorter billing windows and reduce the administrative friction for providers.

If you’ve been uncertain about building or investing in RPM/RTM — this is your sign.

2. Behavioral Health Add-Ons for Primary Care

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Next: behavioral health integration inside primary care finally becomes logical.

APCM created a structure for primary care payments, but in 2026 CMS is adding optional add-on codes that allow practices to bill for behavioral health or collaborative care in the same month as APCM.

Why it matters:
This aligns payment with reality.
Patients don’t separate physical and mental health — now Medicare won’t either.

Primary care clinics can:

• Hire behavioral health clinicians

• Contract with digital mental health platforms

• Integrate care without losing reimbursement

Startups now have a clear billing pathway to embed mental health into primary care.

If the economics never worked before, 2026 changes the equation.

3. A Real Financial Nudge Toward Value-Based Care

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Now, the money question.

CMS is increasing payments after years of cuts. Across the board, services go up roughly 2.5%.
But here’s the key difference:

• Providers in qualifying APMs get an extra 0.75%

• Providers not in APMs get 0.55%

That totals:

• 3.8% for APM participants

• 3.6% for non-participants

It may sound small, but across panels and service lines, it adds up.

CMS is sending a clear message:
Value-based care is the direction of travel.

If you’ve hesitated about joining an ACO or specialty model, use this as your financial nudge.

Startups can support this shift with analytics, quality tools, risk scoring, and population health infrastructure.

4. Digital Therapeutics and Telehealth Expansion

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This one is significant.

CMS is expanding consideration for reimbursement of digital mental health services and devices, starting with ADHD. They’re also asking for input on digital tools for GI issues, sleep disorders, fibromyalgia, and autism diagnosis.

Plus:

• A smoother process for approving new telehealth codes

• More flexibility in the Medicare Diabetes Prevention Program

• Support for virtual and asynchronous delivery

Why it matters:
Digital health is moving from “temporary emergency measure” to a long-term, reimbursable part of Medicare.

Clinics should modernize telehealth workflows.
Startups building digital therapeutics, chronic care apps, and AI tools are being openly invited into Medicare’s ecosystem.

The door is now wider than ever.

5. The Big Outpatient Shift

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Finally, a structural shift.

CMS is changing how it calculates practice expense values. Since so many physicians are now hospital-employed, CMS is no longer assuming those physicians maintain separate offices.

The impact:

• Higher reimbursement for office-based procedures

• Lower reimbursement for hospital/facility-based procedures

And it goes further.

Beginning in 2026, CMS will phase out the inpatient-only list over three years.
This includes 285 musculoskeletal surgeries — hips, knees, orthopedics — and adds more than 500 procedures to the ASC covered list.

Why it matters:
Hospitals lose exclusive control over certain surgeries.
ASCs and advanced clinics gain opportunity.

Startups supporting ASCs with pre-op optimization, post-op monitoring, and navigation suddenly have a large growth runway.

This outpatient shift is now embedded in Medicare policy.

Summary: Your 2026 Playbook

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1. Shorter billable monitoring windows

2. Behavioral health add-ons for APCM

3. Larger bumps for value-based care participants

4. Expansion of telehealth and digital therapeutics

5. A major shift toward outpatient surgical care

These updates all point in the same direction:
More flexible, more digital, more integrated, and less dependent on hospital settings.

If you run a clinic — adapt your workflows now.
If you’re building a startup — design your product to help providers capture this revenue and excel in value-based care.

This isn’t about surviving Medicare changes.
It’s about turning them into an advantage.

I’m Alex Yarijanian.
Thanks for listening — and remember: the future of healthcare favors those who adapt early.