TARGET 2026!
- John Spiezio
- Jan 4
- 3 min read
Updated: Jan 6
TARGET 2026!
Successfully TARGET 2026 with updates and recommendations from SMBS!
Sound Medical Billing Solutions can help you TARGET 2026!
Medicare Deductible and Therapy Cap Thresholds
2026 Medicare Deductible: $ 283.00 (+$ 26.00)
2026 Medicare Therapy Cap: $ 2,480.00 (+$ 70.00)
Targeted Medical Review: $ 3,000.00 (no change)
Important Notes:
A patient enrolled in a Medicare Home Healthcare Plan of Care is NOT eligible for Part B services
A patient enrolled in a Medicare Advantage Plan is NOT enrolled in Empire Medicare (see details below)
New Year - New Insurance Verification
With the start of the new year, many patients change insurance plans. Even patients who retain their current carrier may experience new policy requirements effective January 1, 2026.
To best serve your patients and reduce claim denials, SMBS recommends the following:
Insurance Card Collection
Request each patient present all new 2026 insurance cards (primary, secondary, and tertiary).
Insurance Information Verification
Confirm the information presented matches what is on file:
Has the insurance carrier changed?
Has the ID number changed?
Has the guarantor changed?
Benefits Verification
Verify benefits with each payer to determine:
Is the patient covered under the policy?
What is the patient’s financial responsibility (co-payment, co-insurance, deductible)?
Note: Benefit details often change in the new year.
What are the pre-authorization requirements, and do prior authorizations carry over into the new plan year?
Clinical & Administrative Actions
Perform a new evaluation and bill 97161(2)(3) when a new primary insurance becomes active.
Complete a new intake form to document insurance changes so a new account can be created.
Strategies to TARGET 2026
Proven strategies to increase revenue and ensure compliance in 2026:
Review office procedures to ensure comprehensive document collection and insurance verification.
Review and update front office-to-billing workflow to supports clean, valid claims.
Ask patients to confirm insurance coverage at each visit or following a lapse in treatment.
Collect patient balances at the time of service.
Note: It is significantly easier to refund an overpayment than to collect a balance after discharge.
Eliminate courtesy forgiveness of patient balances.
Note: Routine waiver of patient financial responsibility may violate contractual obligations.
Review credentialing and network participation to eliminate PPO reductions.
Note: PPO enrollment may reduce Worker's Compensation and No-Fault payments up to 60%.
Author comprehensive, defensible documentation that meets Medicare guidelines.
Note: Review Medicare guidelines and perform a self-audit to ensure documentation compliance
Analyze current treatment and documentation procedures to ensure billing compliance with the 8-minute rule, and charges of Re-Evaluation 97164.
Develop alternative revenue sources to support long-term practice stability.
Medicare Advantage Programs - Understanding the Confusion
Medicare Advantage Plans are often misunderstood by both patients and providers. Advertised as Medicare Part C, these plans are third-party commercial insurance products marketed to Medicare-eligible individuals and are not government health plans.
For providers, Medicare Advantage Plans frequently require:
Pre-authorization
Provider Network credentialing
For patients, these plans often result in higher out-of-pocket costs, including co-payment, co-insurance, and deductible responsibilities.
Patients may believe they “have Medicare” and present both a Medicare ID card and a Medicare Advantage card.
Important Note:
All Medicare eligible patients possess a Medicare identification card; however, this does NOT confirm enrollment in traditional Medicare. Verification of benefits is essential to avoid unpayable or untimely claims.
Steps to Ensure Payable Medicare Advantage Claims
Identify patients enrolled in Medicare Advantage Plans and any changes to supplemental insurance. Note: Verifying benefits directly with Medicare helps identify Medicare Advantage enrollment.
Identify Medicare Advantage benefits.
Communicate patient financial responsibility and obtain a signed benefits estimate.
Note: Patients enrolled in Medicare Advantage plans often do not carry supplemental insurance.
Collect all patient financial responsibilities at the time of service.
Note: It is significantly easier to refund an overpayment than to collect a balance after discharge.
Obtain all required pre-authorizations prior to treatment.
For additional details regarding 2026 governance or for guidance on your practice needs,
contact SMBS for a personal practice review.
SMBS wishes you a happy, healthy, and profitable 2026!
Give us a call and we can help you TARGET 2026!
Let us provide your SOUND MEDICAL BILLING SOLUTIONS!
John Spiezio, President
Sound Medical Billing Solutions, LLC
The Outpatient Rehabilitation Practice Management and Billing Specialists!
Call, click, or email for more information about this or any other topic that may affect your practice. We will be happy to help!
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