If you are billing RPM for Diabetes, Hypertension, or COPD under UHC, your claims will likely be denied starting January 1st.

If UnitedHealthcare (UHC) is a significant payer for your practice, you need to audit your Remote Patient Monitoring (RPM) panel immediately.

Quietly buried in their December 2025 policy bulletins, UHC has announced a massive restriction on RPM coverage that goes into effect January 1, 2026.

Unlike CMS, which is expanding remote care through new payment models like APCM, UHC is moving in the opposite direction. They are adopting a strict "proven vs. unproven" stance that effectively eliminates RPM coverage for the vast majority of chronic conditions.
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The New HF/HDP Standard

Starting Jan 1, UHC will consider RPM "Proven and Medically Necessary" for only two primary indications:

1. Heart Failure (HF)
2. Hypertensive Disorders of Pregnancy (HDP)

For almost every other common chronic condition, including Type 2 Diabetes, Essential Hypertension, COPD, Anxiety, and Sleep Apnea, UHC has explicitly flagged RPM as "Unproven and Not Medically Necessary."

What This Means for Your Revenue

If you are currently billing codes 99453, 99454, or 99457 for a UHC patient with diabetes or standard hypertension, you face a high risk of automated denials beginning in the new year.

This applies across Commercial, Medicare Advantage, and Medicaid (Community Plan) lines of business.

Dont Panic. Pivot.

This policy change is aggressive, but it is manageable if you act before the deadline.

• You need to identify every UHC patient currently on RPM.
• You need to verify if they have a qualifying Heart Failure or Pregnancy diagnosis.
• If they don't, you need to transition them to Chronic Care Management (CCM) or other care models before Dec 31st to avoid revenue disruption.

Get the Red Alert Survival Guide

We have compiled a comprehensive resource breakdown of this policy update. It includes the specific policy numbers, a decision tree for your patient panel, and a guide on which "safe harbor" codes (like CCM and RTM) are still viable.

👉 Read the Full Guide: The 2026 UnitedHealthcare Remote Care Shift

How We Automate This Rule

Reading the policy is one thing. Enforcing it across 2,000 patients is another. In FairPath, our Payer Ontology now reflects the 2026 UHC restrictions and automatically cross-references Payer (UHC), Diagnosis (I10 vs I50.9), and Program (RPM) so teams know where RPM is and is not covered.

• Patient records are evaluated against the updated UHC policy logic inside the Payer Ontology.
• When a UHC member is tied to a non-covered diagnosis for RPM, the enrollment workflow surfaces a clear “Not Covered” flag.
• Clinicians and staff can redirect patients into APCM/CCM-first pathways without wasting setup time or billing attempts.

Related Resources for Your 2026 Strategy

The UHC shift is just one part of a chaotic year for remote care. As you restructure your remote care program, use these tools to ensure you remain profitable and compliant:

• The CMS Strategy: While UHC restricts, CMS is expanding. Learn how to pivot to the new Advanced Primary Care Management model. Read the Guide: CMS 2025-26 APCM/RPM
• The Economics: Losing RPM coverage for UHC patients hurts. See how it impacts your bottom line if you are still paying a vendor. Run the Vendor Profit Analyzer
• The Compliance Check: With policies changing this fast, audits are inevitable. Ensure your documentation is bulletproof. Download the 2026 OIG Audit Survival Guide

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Originally published at: https://fairpath.ai/resources/cms-rpm-apcm-2025-26
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If you run an independent practice, there is a good chance remote patient monitoring is a sore subject.

You might hear the term “RPM” and immediately think of a vendor that overwhelmed your staff with devices, made big promises, and left you with documentation that never felt stable once audits became real. They left you with messy documentation and a billing setup that never felt like it would survive a serious review.

During COVID, RPM was marketed as the lifeline that would keep the doors open. In reality, for many practices, it became a source of anxiety that has not fully gone away. It is understandable that a lot of physicians and practice leaders have mentally put RPM into the “failed experiment” bucket.

The problem is that this is not actually how CMS is treating these programs.
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CMS Still Sees Value in Remote Monitoring

If CMS believed RPM was a mistake, it could have quietly starved it of oxygen. That is not what happened.

RPM survived the pandemic and was refined. The codes stayed in the Physician Fee Schedule. The rules were adjusted. New flexibilities were introduced alongside new scrutiny. All of that signals something important: CMS still sees real clinical and financial value in remote monitoring. The agency simply wants that value delivered in a more disciplined, predictable way.

Underneath the audits and enforcement activity there is a bigger policy shift. CMS is trying to move primary care away from purely episodic visits and toward relationship-based, continuous care. The long-term goal is simple: more patients in accountable care arrangements, fewer patients in a fragmented, visit-only model.

This is the context for the new Advanced Primary Care Management (APCM) benefit. If you want the code-level, practice-facing details, we’ve put them in a full guide on FairPath: What CMS’ 2025–26 Rule Changes Mean for RPM & APCM (and How to Run Them In-House).
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What Went Wrong During the Pandemic

When the pandemic hit, RPM went from an interesting idea to a crisis tool almost overnight. Practices were locked down. Patients were at home. Fee-for-service revenue was evaporating. Third-party vendors moved quickly with turnkey offers and aggressive projections. Many practices, quite reasonably, focused on survival rather than on designing a long-term care model.

In that environment:

• Panels were sometimes built around whoever would answer the phone instead of around clinical risk.
• Time tracking and documentation were often treated as something the vendor would “handle,” instead of as a core compliance responsibility for the practice.
• Internal governance was thin because everyone was exhausted and just trying to get through the year.

Fast forward a few years and OIG is now doing exactly what you would expect. They are asking how many patients were enrolled, what work was actually done, and whether the documentation supports what was billed. For some practices the answer is clean. For others, the records tell a more complicated story.

If you read between the lines of recent rule-making and OIG reports, a clear narrative emerges: the government is tired of paying for device mills.
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The Pivot to APCM: From Device Mills to Continuous Management

For the past five years, much of the RPM industry has been dominated by a specific type of vendor: one that ships thousands of Bluetooth blood pressure cuffs, collects 40–60% of the practice’s revenue, and generates reams of PDF reports that often sit unread in a portal.

OIG has noticed. Their work highlights waste in “device-only” billing and a lack of care coordination. CMS’ answer is not to kill remote care; it’s to redesign how it’s paid for.

That redesign is APCM.

APCM is not a niche experiment. It is CMS taking years of lessons from CCM, care-management demonstrations, and remote-technology codes and wrapping them into a monthly payment for the real work primary care teams do between visits.

The important detail is that APCM is structured as three levels that map to patient complexity, not to how many minutes someone spent on a timer or how many times a patient stepped on a scale.

• The lowest level is the Medicare patient with little or no chronic disease burden.
• The middle level is the patient with multiple chronic conditions who is at genuine risk of decompensation or hospitalization if the practice does not keep a steady hand on their care.
• The highest level is the patient who is both clinically complex and financially vulnerable.

Each level carries a different payment amount, but the underlying idea is the same:

primary care teams are doing meaningful coordination work and CMS is willing to pay a predictable, per-member amount for that work.

Notice what is absent from that description:

• No requirement that a nurse hit a precise 20- or 30-minute threshold on a stopwatch every month.
• No requirement that every eligible patient has to be wearing a device.

There is still a clear expectation that defined service elements are delivered and documented. There is still an expectation that patients have access and support between visits. But the emphasis has shifted from timer management to team-based, relationship-centered care.

That shift makes the old outsourced RPM model much harder to justify.

APCM is designed to be run by the practice, not by a call center. It rewards 24/7 access, comprehensive care planning, and continuity—things an outsourced vendor cannot genuinely provide.
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A New Mental Model: APCM as the Base, RPM as Intensification

This creates a different mental model for operations.

In the older view, you were either “doing RPM” or you were not. You either had a chronic care management vendor or you did not. Each program sat off to the side of your core clinic operations and had to justify itself on its own. Remote care was a bolt-on product line.

APCM pulls those activities back toward the center. It says, in effect, that a primary care panel can be treated as a managed population. Many Medicare patients can be inside some version of a structured, between-visit care model where the practice is paid to keep an eye on them, adjust plans, coordinate with specialists, and intervene before a crisis.

Once you see APCM that way, RPM looks different too:

• RPM stops being a standalone “business line.”
• It becomes a selective intensification of care for the patients who truly need it.

An APCM-enrolled patient with stable chronic conditions might never need a device. Another patient with brittle heart failure or complex hypertension might clearly benefit from structured device-based monitoring layered on top of their APCM relationship.

In that world, the real work is not “sign up as many patients as possible for RPM.” The real work is designing a coherent panel strategy:

1. Which Medicare patients fit your APCM framework, and at what level.
2. Which APCM patients truly justify the added complexity of RPM.
3. How you will govern and audit the whole arrangement.

Any practice that offers RPM and care management without a written set of eligibility criteria, workflows, and spot checks is taking unnecessary risk. After the last few years, a modern remote-care program should have the same level of internal oversight as a high-risk in-office procedure.
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Why We Think the Future Is Vendor-Free

Put these pieces together and the picture looks very different from the “RPM gold rush” days.

CMS is still paying for remote monitoring. In some ways it is paying more flexibly than before. At the same time, it has built APCM as a new backbone payment that can cover almost an entire Medicare panel at different levels of complexity. The audits and the new program design are two sides of the same coin.

The message is not “stop doing remote care.” The message is closer to:

“Use remote care in a structured, accountable, primary-care-first way,  and stop outsourcing your audit risk.”

We believe the future of remote care is vendor-free:

• Practices should use software to automate logistics and compliance checks.
• Practices should own the clinical relationship and the revenue.
• Vendors who take 40–60% of your RPM check for running a call center don’t fit where CMS is going.
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Get the Full, Practice-Facing Breakdown

This post is the strategic view. If you’re a physician, medical director, or practice manager and you want the practical, practice-facing details, we put them in a full guide on FairPath:

👉 What CMS’ 2025–26 Rule Changes Mean for RPM & APCM (and How to Run Them In-House)

That guide covers:

• A line-by-line comparison of vendor-based RPM vs in-house APCM/RPM economics.
• A check-list for 2025–2026 OIG/RPM audit readiness.
• How to design an “APCM-First” panel strategy where RPM is used only when it clearly changes care.
• How to structure a vendor-free remote care program so your team stays in control.
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Want to See Actual Numbers for Your Panel?

If you want to see what an APCM-first, vendor-free model looks like in dollars for your specific panel size, we’ve also published a simple calculator on FairPath:

👉 Run the Reimbursement Calculator(See what APCM + in-house RPM could generate — without rev-share.)

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Most independent practices didn’t launch remote care programs so they could track timers, chase scattered documentation, or argue with spreadsheets at the end of every month. They adopted RPM and CCM because they believed these programs would keep patients out of the hospital, create stability in a turbulent reimbursement environment, and help them deliver more modern, continuous primary care. Yet inside almost every in-house RPM or CCM workflow, there is a moment that rarely gets acknowledged out loud. It happens when a nurse looks at the log and sees the number that makes their stomach drop: 18 minutes.

In that moment, the nurse faces a choice that should never exist in a legitimate care-management model. Do they round the time up so the practice can bill? Or do they leave it as-is and lose revenue for work that genuinely occurred? This is the moment where the system forces good clinicians into untenable decisions. This is the moment I call the Minute Trap.
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The Minute Trap: When Good Work Collides With Bad Rules

In nearly every practice I’ve supported, the pattern is identical. The clinical work is real. The touchpoints are real. The patient benefited from the engagement. But the documentation sits just shy of the threshold, and the nurse is juggling a high patient load in an understaffed environment, often at the end of a month that’s already stretched them thin. In that moment, the nurse is not thinking like a fraudster—far from it. They’re thinking like someone who wants to do right by patients, support the physician, and avoid being the reason the practice misses out on earned revenue.

Rounding up feels like a harmless adjustment. But CMS and the OIG don’t see nuance in these situations. They see a claim that doesn’t align with the rules as written. Over time, this quiet monthly pressure reshapes culture. Teams begin to normalize comments like, “Everyone does it,” or “We’ll fix the workflow later,” or “We can’t afford to leave money on the table.” This isn’t a training issue or a sign of a disengaged staff. It’s not about hustle or work ethic. It is the predictable fallout of a structural flaw in how minute-based remote care has been designed.
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Why In-House RPM Isn’t Automatically Safer

Many practices brought RPM in-house believing it would increase control, strengthen clinical alignment, and reduce expenses tied to outside vendors. And on paper, that logic seems sound. But in practice, in-house programs often carry more risk precisely because the pressure, documentation, and billing decisions all occur inside the same walls.

What I see consistently is that minutes are scattered across multiple systems, handwritten notes, or EHR messages that don’t map cleanly to billable documentation. There is rarely a single, audit-ready source of truth. Documentation and billing often drift apart, especially during end-of-month catch-up periods. And nurses—who entered healthcare to care for people, not to play timekeeper—end up responsible for both clinical continuity and revenue capture. Under these conditions, the “18-minute decision” isn’t an outlier. It’s built into the operating system of the program. The real cost of an in-house RPM program is not the staff time required to run it; it’s the compliance exposure created when documentation and billing logic don’t match.
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APCM: Moving From Minutes to Care Elements

Advanced Primary Care Management (APCM) provides a way out of this cycle. Instead of tying reimbursement to a stopwatch, APCM organizes care around care elements—the actual clinical actions and interventions that define good longitudinal care. These include risk stratification, medication reconciliation, chronic condition follow-up, patient education, coordinated interventions, escalations, and longitudinal care patterns. In other words, APCM aligns reimbursement with how clinicians naturally think and work.

This framework allows practices to dramatically reduce reliance on manual minute tracking. It strengthens documentation integrity and lowers false-claim exposure. It gives physicians confidence that their license is protected. And it gives nurses permission to focus on clinical care instead of managing a countdown timer. The question for practices becomes less about whether they are “working hard enough” and more about whether their care-management structure is defensible, repeatable, and aligned with where CMS is taking primary care.
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Why This Matters for 2025

CMS is steadily shifting away from minute-threshold logic and toward models that value comprehensive, longitudinal care. That shift will place increasing scrutiny on documentation quality, consistency between systems, audit readiness, and clinical justification. Practices that continue relying on hourglass-based workflows will find the pressure intensifying. Practices that embrace a care-element approach will not only reduce exposure—they’ll build a stronger foundation for growth.

Administrators, office managers, and medical directors feel this dynamic more than anyone. They are the ones balancing compliance, operations, staffing, documentation, and revenue integrity every single month. They see the 18-minute problem long before anyone puts a name to it. And the truth is: this problem is solvable. But it requires a system designed for how real care happens—not how time is captured.
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A Better Next Step

If this resonates with you...if you recognize the Minute Trap in your own program…the most productive next step is simply to understand what a compliance-first, APCM-ready care-management environment actually looks like. That’s the foundation of FairPath.

FairPath isn’t built around minute thresholds. It’s built around compliance, care elements, documentation integrity, and workflows that protect the practice rather than expose it. It supports RPM, CCM, RTM, and APCM in one unified structure and eliminates the operational and ethical tension clinicians face at the end of every month.

If you want to see how modern practices are removing the Minute Trap entirely, visit:
FairPath.ai

It outlines how compliance-first design works, how APCM-style care is structured, and how practices are preparing for 2025 and beyond. Most teams don’t need to “work harder.” They need a system that reflects the reality of care, and it shouldn’t be a “minute hand”.

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The $1.2 Million Mistake Most Practices Are Making Right Now

If your practice adopted APCM by shutting down RPM and RTM programs, you left money on the table. If you're running all three programs separately, you're burning cash on duplicate documentation and exposing yourself to compliance risk.

The correct answer isn't either-or, its coordinated integration. Practices that get this right are generating $225-325 net margin per patient monthly while reducing administrative burden by up to 30%.

Here's how the economics actually work, and what separates winning practices from everyone else.
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Why Practices Get This Wrong

CMS introduced APCM as a structural upgrade to care management, not a replacement for monitoring programs. Yet most practices treat it as one:

The Replacement Trap: Practices abandon profitable RPM and RTM programs, assuming APCM covers everything. It doesn't. You lose monitoring revenue and weaken care continuity.

The Silo Trap: Practices run all three programs independently, creating redundant workflows, conflicting documentation, and billing errors that invite audits.

Both approaches cost you money. The first sacrifices revenue. The second burns it on overhead.
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The Integration Model: Three Programs, One System

Successful practices recognize that APCM, RPM, and RTM serve distinct clinical and financial functions:

APCM provides the overall care management structure—provider accountability, care planning, and transition management.

RPM and RTM deliver continuous patient data that drives specific interventions within that structure.

Integration means these programs share one care plan, one documentation system, and one accountability framework. You bill separately for each service, but you execute them as a unified operation.
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What This Looks Like Operationally

Single Care Plan: RPM glucose readings or RTM therapy adherence data flow directly into the APCM care plan, triggering interventions automatically.

Unified Task Management: All outreach, education, and monitoring tasks appear on one centralized list—not scattered across three platforms.

Automated Documentation: Software captures activity in real time, meeting all program-specific billing requirements without duplicate data entry.

One Accountability System: Care navigators, nurses, and providers coordinate under a single supervisory framework rather than juggling separate program rules.

This eliminates the false trade-off between patient volume and compliance. Practices scale both simultaneously.
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The Financial Case: Real Numbers from In-House Programs

Most practices running siloed programs capture $150-180 per patient monthly across RPM or basic care management. They're leaving significant reimbursement unclaimed.

Integrated in-house APCM + RPM + RTM programs using modern automation generate $250-350 per patient per month in combined reimbursement. Program costs run approximately $25 per patient monthly ($10 software, $15 per device rental).

Net margin per patient: $225-325 per month, depending on complexity and time documented.

Staffing efficiency compounds these gains. In siloed programs, a three-person care team (two RNs, one MA) manages 600-700 patients due to documentation overhead and system friction. Integrated systems with automation enable the same team to handle 900-1,000 patients while maintaining compliance.

The financial impact is substantial:

Traditional siloed model:

• 700 patients × $160/month = $112,000 monthly gross revenue
• Higher admin overhead, fragmented workflows
• Est. 40% margin after labor and overhead = $44,800 monthly profit

Integrated in-house model:

• 950 patients × $290/month = $275,500 monthly gross revenue
• ~$25/patient program costs = $23,750 monthly
• Same care team, 25% less admin time
• Est. 55% margin after all costs = $151,525 monthly profit

That's a $106,725 monthly difference, or $1.28 million annually, with identical headcount.

These figures reflect actual CMS reimbursement rates and reported results from practices running integrated programs in 2024-2025. The difference comes from eliminating waste and capturing all available compliant reimbursement—not from aggressive billing.

Clinical Scenarios Where Integration Drives Value

Chronic Disease Management (RPM + APCM)

A diabetes patient's RPM glucose monitor flags elevated readings. In an integrated system, those readings automatically update the APCM care plan and trigger an intervention protocol. One documentation event satisfies both programs' billing requirements.

Post-Surgical Rehabilitation (RTM + APCM)

A patient recovering from knee surgery stops engaging with home therapy exercises tracked through RTM. Integrated software alerts the APCM care team immediately, enabling intervention before outcomes deteriorate. Both programs bill compliantly from the same workflow.

Complex Post-Hospitalization Care (RPM + RTM + APCM)

A COPD patient discharged from the hospital needs breathing monitoring (RPM), therapy adherence tracking (RTM), and transition management (APCM). All three run from one system, preventing readmission while maximizing compliant reimbursement.

In each case, integration creates clinical value and financial value simultaneously—not by gaming the system, but by eliminating waste.

Compliance: The Four Non-Negotiables

Integration increases revenue only if you maintain clear program separation in documentation and billing:

Differentiate Services Clearly: Document what RPM, RTM, and APCM each provide. Never blur the lines.

Prevent Time Overlap: If you bill 20 minutes for APCM, that same 20 minutes cannot count toward RPM time requirements.

Document Care Transitions: APCM requires thorough transition documentation. Automate this wherever possible, but verify completeness.

Audit Monthly: Run internal reviews to catch billing errors before external audits do.

Automation handles most of this oversight, but governance remains essential. The practices that avoid trouble treat compliance as a system design problem, not a documentation problem.

Why Automation Is Non-Negotiable

Integration without automation is theory. Automation makes it operational reality.

Platforms like FairPath centralize patient records, automatically manage care tasks against billing criteria, and generate audit-ready documentation in real time. This isn't about convenience—it's about making integration financially viable.

Without automation, the administrative load of running three coordinated programs exceeds the efficiency gains. With automation, you unlock the full revenue potential while reducing overhead.

What to Do Next

If you're running APCM, RPM, or RTM in isolation, you're likely generating $150-180 per patient monthly—and leaving $100-170 per patient unclaimed. If you're avoiding APCM because you think it conflicts with existing programs, you're missing a seven-figure annual opportunity.

The strategic question isn't whether to integrate. It's how quickly you can operationalize integration with the right automation and cost structure to capture $225-325 net margin per patient.

Do This Next:

1. Audit your current APCM, RPM, and RTM programs separately—identify overlap, gaps, and billing inefficiencies
2. Calculate your current per-patient monthly net margin across all programs (including software and device costs)
3. Model the revenue impact of full integration using the $225-325 net margin per patient benchmark and your current census
4. Evaluate whether your current software can support unified workflows or if you need a purpose-built platform
5. Schedule a 45-minute APCM Integration Review to map your specific opportunity and compliance requirements

Integration isn't the future of care management—it's the present. The only question is whether you'll capture the opportunity this year or watch competitors do it first.
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Disclaimer: This article provides general information only. Specific reimbursement rules and eligibility vary by MAC, payer, and contract year. Consult with compliance and billing specialists before implementing new programs.

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