September 15, 2026
The CY2027 proposed rule turns on three pieces of regulatory language that most clinic owners have never had to think about. If the outsourcing provision is finalized, they become the vocabulary that decides whether your RTM claims get paid.
They are worth understanding now, because two of them already apply to you and you may not be meeting them.
Direct employee
This is the new one, and it is the sharp edge of the proposal. CMS would require that clinical staff performing RPM or RTM monitoring be a direct employee of the billing practitioner or of that practitioner’s practice.
The word direct is doing a lot of work. In Medicare usage it draws a line between someone on your payroll and someone whose services you purchase. A W-2 employee of your practice is clearly inside the line. A contractor supplied by a monitoring vendor is clearly outside it. The interesting cases are in between, and the proposed rule does not resolve them cleanly.
If you use a staffing agency to place a PTA in your clinic, is that person a direct employee? If you own two entities and the monitoring staff sit in one while the billing NPI sits in the other, does that count? If a 1099 clinician works only for you, thirty hours a week, under your supervision, is that direct?
Nobody knows yet. That ambiguity is one of the better things to raise in a comment before September 14, because agencies do respond to requests for clarity even when they do not change the underlying policy.
General supervision
This one already applies and most practices already meet it, but it is worth restating because people confuse the supervision tiers.
General supervision means the service is furnished under the billing practitioner’s overall direction and control, but the practitioner does not have to be physically present while it happens. That is the loosest of the three Medicare tiers. Direct supervision would require the practitioner to be in the office suite and immediately available. Personal supervision would require them in the room.
RTM monitoring runs under general supervision. Your PTA can call a patient on Tuesday while you are treating someone else, or working from home, or on vacation, provided the overall direction and control relationship is real and documented. If your only evidence of direction and control is that you signed something in January, that is thin.
Incident to
Incident-to billing is the mechanism that lets services performed by clinical staff be billed under the practitioner’s NPI. It comes with conditions: the service is an integral part of the patient’s course of treatment, the practitioner performed the initial service and remains actively involved, and the staff member is qualified for what they are doing.
The phrase in the proposed rule is that all other incident-to requirements must be met. That sentence is short and carries a lot of freight, because incident-to has been a common audit finding in other parts of Medicare for years.
For a PT practice the practical translation is this. You evaluated the patient. You built the plan of care. The monitoring your staff performs is part of executing that plan, not a separate service running alongside it. And you remain involved in a way a reviewer could see in the chart.
What to actually do with this
Two of these three already govern your program. If the outsourcing provision never gets finalized, general supervision and incident-to still decide whether your claims survive review, and they are where I would spend attention first.
Pull five RTM charts from last month. For each one, find the evidence that you directed the care, that the monitoring connected to your plan of care, and that the person who performed it was qualified. If you cannot find it quickly, a reviewer will not either.
Then look at the direct-employee question against your own arrangement. If your monitoring is performed by anyone who is not on your payroll, write down exactly what that relationship is. You will need that description either to comment on the rule or to restructure before January.
What this means for your clinic
If your monitoring staff are W-2 employees of the billing practice, the proposal leaves you alone and your work is documentation quality.
If they are contracted from a vendor, including from us, the direct-employee language is the one to read carefully and the one to comment on.
If you are somewhere in the middle, with shared entities or long-term contractors, you are in the ambiguous zone, and that is worth raising with CMS explicitly before September 14.
The rule is Federal Register document 2026-14327.
If you want to walk through how your specific arrangement reads against this language, request a demo and we will go through it with you. If you would rather start with the money side, the RTM calculator will show what the staffing math looks like either way.