September 8, 2026
Most of the attention on the CY2027 proposed rule has gone to the outsourcing provision, which is understandable because it is dramatic. I think a quieter change will disqualify more claims.
CMS has proposed extending to RTM the established-patient requirement that already applies to remote physiologic monitoring. Before you furnish and bill RTM, the billing practitioner must have an established relationship with the patient.
Why this is less obvious than it sounds
Read against how a well-run clinic actually enrols patients and you find edge cases quickly.
A patient is evaluated by one therapist in your practice and monitored under a plan of care managed by another. Which one needs the established relationship, and does your documentation show it.
A patient completes an episode, is discharged, and returns eight months later for a new complaint. Are they established for the new episode, and what evidence would you show.
A patient is seen once for an evaluation and enrolled in monitoring at that visit. Is one encounter enough to establish the relationship.
None of these are exotic. They are Tuesday.
The initiating visit sits alongside it
The proposal also requires a separately reportable initiating visit in connection with the start of monitoring.
For a clinic where every patient is evaluated in person before anything else happens, this is mostly a documentation exercise. For anyone enrolling patients remotely, at discharge from another setting, or through a referral pipeline that does not begin with an in-person evaluation, it is a workflow change.
The combination is what matters. Established relationship plus a reportable initiating visit means RTM cannot begin before a documented clinical encounter that you can point to.
Why I think this bites harder than the ban
The outsourcing provision is loud and contested. The industry will fight it, and there is a reasonable chance it is narrowed before the final rule.
The established-patient and initiating-visit requirements are neither loud nor contested. They align RTM with rules that already govern RPM, which makes them easy to finalize and hard to argue against. I would plan on them surviving.
And they fail differently. An outsourcing ban forces a visible decision about staffing. An established-patient requirement fails silently, one claim at a time, on patients whose enrollment path did not quite fit. You find out in an audit.
What to do about it now
Map your enrollment paths. Write down every route a patient can take into your RTM program. Most practices have three or four and have never listed them.
For each path, identify the encounter that would satisfy an established relationship and confirm it is documented in a way a reviewer could find.
Find the paths that would fail. The usual suspects are enrollment at discharge from another provider, enrollment driven by a referral without a completed evaluation, and re-enrollment of a former patient after a gap.
Then decide whether to change the path or stop using it.
The useful part is that this is worth doing regardless of what the final rule says. Being able to show a documented clinical relationship behind every monitored patient is good practice under the current rules too.
What this means for your clinic
Do the enrollment path mapping this month. It takes an hour and it is the only preparation that pays off under every version of the final rule.
Do not wait for November. If a path needs changing, changing it in December while also absorbing whatever else the final rule brings is worse than doing it now.
And if you comment before September 14, this is a good area to ask for clarity on rather than to oppose. Agencies respond to specific questions about how a requirement applies to real workflows. Our post on how to write a comment CMS will weigh has the structure.
The rule is Federal Register document 2026-14327. If you want to talk through your own enrollment paths, request a demo and we will go through them with you.