CMS Is Regulating the Wrong Thing — Here’s How to Fix Remote Patient Monitoring Without Losing the Care

CMS’s proposed 2027 Physician Fee Schedule makes several changes to Medicare’s rules for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM). The proposal would require an initiating visit before RPM or RTM services begin, extend the established-patient requirement to RTM, and allow payment for RPM and RTM only when the clinical staff furnishing the services are direct employees of the billing practitioner or practice.

CMS says the changes are intended in part to address program-integrity concerns identified by the HHS Office of Inspector General, including evidence that some Medicare beneficiaries receiving RPM did not receive all of the required components of the service. That’s a problem worth solving.

However, CMS’s proposed solution raises a fundamental question: Why should Medicare determine who is qualified to provide remote monitoring by asking who employs the nurse, rather than who is accountable for the patient’s care?

The goal of any new rule shouldn’t be to preserve every existing RPM business model, but to preserve high-quality remote care while eliminating the practices that create the oversight and program-integrity problems CMS is trying to address.

CMS is right about the problem: Remote monitoring needs accountability

CMS’s proposed rule specifically argues that outsourcing can fragment care, lead to insufficient involvement and oversight by the billing practitioner, or result in services that do not satisfy the full requirements of RPM or RTM. CMS is also responding to documented problems in the existing system. An HHS OIG report found that 43% of Medicare enrollees receiving RPM in 2022 did not receive all three required components of the service.

The answer to those problems should be stronger accountability for the care being delivered — not necessarily a prohibition on the organizational structure used to deliver it. A nurse’s W-2 status doesn’t establish by itself whether a physician is appropriately supervising the care, whether alerts are being reviewed, whether patients are being engaged, or whether the service is clinically integrated into the patient’s care.

Conversely, a contracted clinical team can be held to defined standards for supervision, documentation, escalation, communication, and patient outcomes. The regulatory question should therefore be: Who is accountable for the care, and can that accountability be demonstrated?

For maternal health, the value of RPM is what happens between visits

Broad and sweeping policy changes have ripple effects both upstream and downstream. While CMS is primarily looking at the broader category of reimbursement and remote patient monitoring, there is a smaller segment where remote patient monitoring services are absolutely pivotal: maternal health. Pregnancy and the postpartum period illustrate why this distinction matters. A patient’s clinical status can change between scheduled appointments. Remote monitoring can give the care team visibility into those changes without requiring the patient to travel to a hospital or physician’s office every time.

For a pregnant or postpartum patient managing blood pressure or another condition, the value of RPM is not the device itself, or the identity of the person reviewing the data. It is the clinical connection created between scheduled encounters. That connection can be particularly important for patients whose social determinants of health — transportation barriers, living in communities with fewer OB providers, fewer opportunities for in-person care — are stacked against them. What we do know is that maternity care deserts continue to exist and expand across the nation, and remote asynchronous care is a vital modality by which care can be made more accessible and, at the same time, more equitable.

The policy question should therefore be whether the monitoring program is delivering meaningful clinical oversight and measurable benefits between visits. If a remote monitoring program is clinically integrated, appropriately supervised, documented, and demonstrably helping patients, why should its Medicare eligibility turn on whether the nurse works for the hospital or for a qualified clinical partner?

An employment requirement could unintentionally eliminate care where staffing is already scarce

If CMS finalizes the direct-employment requirement as proposed, practices that currently rely on contracted clinical staff would have to bring that work in-house or stop billing Medicare for it.

For large health systems with substantial clinical workforces, that transition may be possible. For smaller practices, rural providers, and OB practices already operating with limited staffing capacity, it may not be. Remote monitoring itself is designed to extend a practice’s clinical reach. Requiring every practice to build its own monitoring workforce could make that reach harder to achieve.

The consequence could be particularly significant for maternal populations that already face access barriers. The unintended consequence is not necessarily that patients receive lower-quality RPM. In some cases, they may receive no RPM at all.

CMS can pursue the same goal by regulating accountability rather than employment

CMS does not need to choose between program integrity and access to remote care. It can establish guardrails that address the problems identified by OIG while allowing providers to use qualified clinical partners. 

Potential safeguards could include:

• A clearly identified clinical entity or practitioner responsible for the patient’s monitoring and management.
• Explicit requirements for the billing practice to retain clinical accountability for the patient.
• Documented protocols for reviewing readings, responding to alerts, and escalating clinically significant findings.
• Auditable records showing who reviewed patient data, when it was reviewed, and what action was taken.
• Minimum standards for patient engagement and data transmission.
• Clear documentation of the relationship between the billing practice and any contracted clinical-monitoring partner.
• Enforcement, including recoupment of Medicare payment, when providers or vendors fail to meet those requirements.

The initiating-visit requirement proposed by CMS could also serve an important accountability function by establishing a clinical relationship and documenting that RPM or RTM is appropriate for the patient. These measures would target the behavior CMS is concerned about directly instead of using employment status as a proxy for quality. The objective should be to make it harder to provide bad remote care, not harder to provide remote care.

The broader lesson: Healthcare policy should regulate outcomes and accountability

Remote monitoring is ultimately a means of extending the clinical relationship beyond the traditional office visit. The healthcare system should care whether the patient is appropriately selected for monitoring, whether the data reaches a qualified clinical professional, whether that professional responds when necessary, and whether the patient’s care team is integrated into the process. Those are measurable questions.

Whether the nurse is employed directly by the hospital, physician practice, or an outside clinical organization is an organizational question — not a measure of care quality. A better policy would hold the provider and its partners accountable for demonstrating that the care works, while preserving flexibility in how that care is staffed and delivered.

CMS has a legitimate responsibility to protect Medicare from waste, fraud, abuse, and poorly integrated care. Solving those problems by restricting RPM and RTM to practices that can employ their own clinical monitoring staff could have consequences for the very patients remote care is intended to reach. For maternal health in particular, the important question is not whether a monitoring nurse sits on a hospital’s payroll. It is whether a pregnant or postpartum patient has a qualified clinical team watching for meaningful changes in her condition between visits.

CMS should strengthen the rules that make providers and their partners accountable for that care. The goal should be simple: regulate the quality and accountability of remote monitoring, not the corporate structure through which it is delivered.

Author bio:

Anish Sebastian is CEO and co-founder of Babyscripts, a maternal health technology company he co-founded in 2014. He has led the company’s growth across health systems, health plans and obstetric practices, with a focus on expanding access to technology-enabled maternity care. Sebastian is a recognized voice on maternal health innovation, remote patient monitoring, reimbursement, value-based care and the operational changes required as pregnancy care moves beyond traditional office-based models.

Photo: gustavofrazao, Getty Images