If you’ve ever wondered why health care is filled with prices nobody can explain, why doctors only spend five minutes with you before sending you out the door with the most billable “treatment,” or why you can find a specialist willing to see you for every organ in your body, but not a primary care physician willing to look at your body holistically and treat root causes of your symptoms — the way health care is coded and valued is probably to blame.
On July 14, the Centers for Medicare and Medicaid Services (CMS) released a draft of the 2027 Physician Fee Schedule, Medicare’s price list, to open for public comment. This year, alongside other strides the agency is making to help address the chronic disease epidemic, the executive branch is looking for something else: a new system for documenting and billing American health care.
The arrangement that determines what medical codes exist, and the value a physician can charge for them, is all federally regulated. It is organized by a complex process that can essentially be boiled down to two realities.
The first is that the American Medical Association (AMA) has the power to permit or block any medical procedure to become an officially recognized and billable procedure. These procedures are given a Current Procedural Terminology (CPT) code, which is the officially adopted national standard coding system for all physician services in the United States (it is also a copyrighted entity of the AMA). Without a CPT code, it is impossible for a doctor to bill an insurance company for a service they provide.
The second reality may shake the free-market supporters a little bit more: the prices that doctors are able to charge for those codes also originate from a body at the AMA, and these prices are set on a yearly basis by representatives of medical specialty societies. The price list that CMS releases each year is based on the recommendations from the 32-member committee at the AMA, which CMS adopts nearly wholesale every year.
Medicare’s list doesn’t only govern Medicare. While private commercial insurers do not have to adopt the price that Medicare sets, all of them contract based on a percentage of it, meaning it is the basis of nearly every payor contract in America.
In layman’s terms, this means a private body of specialty doctors can create, or erase, a medical procedure from the framework of American medicine with no independent check, and another private body in the same organization (under non-disclosure agreements) is setting the price that your doctor is paid for those services.
So, what can you do about it?
Write to CMS and tell them how this system impacts you. This year, the agency is asking the public whether the AMA should continue to hold this power, or if there are alternatives the agency should consider. The Medicare price list notes the ongoing concern with the “monopoly” the AMA holds over CPT coding and the lack of objectivity in the process used to set prices. It even names its own reliance on the coding and pricing processes as a possible contributor to American medicine becoming a “sick care” system with little emphasis on prevention.
You don’t have to be an expert in the field of medicine or insurance to comment. In fact, patient stories can do a lot to establish the current failures of the coding and billing processes. CMS wants evidence of when care was diverted or delayed as a result of the AMA’s control over the codes. Most Americans have that evidence, but haven’t realized it can be used.
Have you ever asked for a test and been told that your insurance wouldn’t cover it? Were you ever handed a prescription to manage a symptom when what you wanted was an explanation of what was causing it? Have you had a claim come back denied as not medically necessary under criteria no one would show you? Did you finally find a physician who could explain what was wrong and discover she didn’t take insurance?
Tell those stories.
If you are a doctor, a nurse, or you work in office billing, you have a sharper version of this than any patient does. CMS wants your comment too.
Comments close on Sept. 14. You can go to regulations.gov and find docket CMS-2026-2377. Reference section II.H, the RFI on the CPT Coding System and Valuation Process. CMS is legally required to respond to significant comments when it finalizes the rule, so your submission really does matter.
This is a monumental chance for Americans to have a say in the way medicine is accessed and paid for across the country. Our medical system is ordered towards quick fixes and expensive specialty procedures, because the people who decide where the pot of federal funds is allocated are the same people with an interest in having their specialty, and the procedures they practice, given the highest values and the most specialized codes. It’s also why an entire specialty area of medicine trying to treat patients’ root causes of infertility is unable to bill for the care they provide because the societies controlling the codes have taken a position against it.
HHS is spending real money this year to train clinicians to diagnose and treat root causes. This administration has made it clear that it is their priority to fix America’s medical system by meeting problems at the source. Let them know how this decision would impact you.
The importance of creating a system designed to foster long-term doctor-patient relationships where prevention and actual treatment are the top priority. You deserve to be able to reach a physician who will look for the true cause of your pain, and that physician should be able to be paid for finding it.
