ARTICLE SUMMARY:
Medicare reimbursement for advanced health software tools like digital therapeutics and AI-based systems ranges from zero to inconsistent. Medtech advocates are hoping CMS will take some tangible steps in two proposed rules next month to improve the situation.
On multiple occasions during the past several years, CMS has solicited input on how it might reimburse for digital health products that present an awkward fit within the Medicare system. Now, developers say it’s time to act.
The agency has an opportunity to establish policy positions in two payment rule proposals due out next month that could help make inroads for two categories of software that have struggled to gain market traction. In particular, sector advocates say they are seeking payment breakthroughs for prescription digital therapeutics in the 2025 physician payment proposed rule and for AI-based software tools to support clinicians in the hospital outpatient proposed rule. (See box, “Background on Payment Rules.”) CMS has leveraged prior-year physician and outpatient rulemakings as venues to think aloud about reimbursement challenges for digital tools, issue formal “requests for information” (RFIs) about possible solutions, and, in some cases, make case-by-case payment decisions for individual technologies.
