When Your Compliance Plan Hits a Sour Note
David M. Glaser, Esq.
January 15, 2026
Monitor Mondays listeners know that I end each segment with a song. Normally the topic drives the song, but to start the new year, the
Grab your pens, alert your billing teams, and cue up your electronic medical record (EMR) vendors, because the Centers for Medicare & Medicaid Services (CMS) just dropped game-changing updates for 2025, and this time, it’s not just about staying compliant – it’s about unlocking real revenue. These changes are for Medicare Part B payments.
Let’s start with vaccines.
Hepatitis B vaccines and their administration will now be reimbursed at 100 percent of reasonable cost. That puts them on the same playing field as influenza, pneumococcal, and COVID-19 vaccines.
Then, starting July 1, a major door will open: you’ll be able to bill for all Medicare Part B preventive vaccines at the time of service. That includes flu, pneumococcal, hepatitis B, and COVID-19. The products will be paid at 95 percent of the average wholesale price (AWP); while administration fees will follow the Medicare Part B National Fee Schedule, these are adjusted by geography.
How it breaks down:
Product payment at 95 percent of AWP;
Administration fees per Medicare Part B’s National Fee Schedule, adjusted for locality; and
One question I get a lot is “what about the in-home vaccine visits?” You can get paid using HCPCS M0201 and get additional payment when all federal requirements are met.
A revenue alert: this is billable, trackable, and completely above-board – but only if your documentation and cost-reporting workflows are meeting the guidelines. CMS will reconcile payments annually based on your cost report, so every dose must be accounted for. Now’s the time to audit your documentation, clean up your cost-tracking, and train your teams to bill with precision. If you get this right? You’ll turn a compliance requirement into a consistent revenue stream.
Let’s talk dental. Another major win: CMS now allows same-day billing for dental and medical services. No more reschedules. If your patients are coming in for both, you get paid for both. This is huge for clinics serving patients with transportation or time barriers.
Finally, CMS is sunsetting the G0511 code and moving toward more granular CPT/HCPCS coding that reflects the real cost of services. Translation? You’ll need to code smarter, track tighter, and get laser-focused on accurate service reporting.
This isn’t just a policy shift; it’s a financial upgrade for those who are ready.
The message from CMS is clear: if you can prove it, you can bill it. Compliance just became a revenue strategy.
Monitor Mondays listeners know that I end each segment with a song. Normally the topic drives the song, but to start the new year, the
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