Medicare paid $5.1 million for remote monitoring in 2019. In 2024 it paid $251.9 million. Press play and watch where the money went — and then look at who ended up holding it, because that is what the CY 2027 rule is actually aimed at.
Remote physiologic monitoring became separately payable in Medicare in 2019: a code to set the patient up, a code for supplying a connected device and sixteen days of readings a month, and codes for the staff time spent managing the data. Remote therapeutic monitoring — the same idea for adherence and therapy response — arrived in 2022.
The CY 2027 Physician Fee Schedule proposed rule would pay for all of it only when the monitoring is performed by clinical staff the practice employs, and not when it is delivered by contractors. To understand why CMS wrote that sentence, start with the shape of the thing it is aimed at.
Three things are visible in that shape.
The first year is almost nothing. 2019: $5.1 million, 427 billing NPIs. A new code family that nobody had built a workflow around yet. By 2020 it was $39.2 million — a 7.7× jump in the year the pandemic made remote anything the only option.
Management time overtook hardware in 2021 and never gave it back. The device-supply code (99454) led in 2019 and 2020. In 2021 the management codes (99457 and 99458) passed it by $2.6 million; by 2022 the gap was $27.5 million, and by 2024 it is $157.1 million against $74.9 million. The growth is in billed staff minutes, which is exactly the input the proposed rule puts a condition on.
It has not flattened. 2023 to 2024 was still +32.1%. Nothing in this curve was slowing down on its own.
Growth alone would not draw a rule. Distribution might. Rank all 8,754 billers by what Medicare paid them in 2024 and walk down from the top:
Eighty-eight NPIs — the top one per cent — hold 24.8% of every remote-monitoring dollar Medicare paid in 2024. Their average monitored panel is 1,614 patients.
Keep going and it stays lopsided: the top 5% hold 46.2%, the top 10% hold 59.7%, and the entire bottom half of billers share 6.8% between them. The median biller is a practice monitoring a few dozen patients. The mean is an artefact of the top of the curve.
A panel of 1,614 Medicare patients, each owed sixteen days of transmitted readings and twenty minutes of documented interactive management every month, is roughly 538 hours of clinical staff time a month. Between three and four full-time people, for one NPI, on one service line. That is the arrangement CMS is describing when it writes “contractors” — and the arithmetic is why the sentence exists.
A large panel under one NPI is not proof of outsourcing. This file credits services to the rendering NPI, and remote monitoring is routinely billed incident-to, so a multi-site group with a dozen employed monitoring nurses looks identical here to a vendor with a contract. Panel size marks where the exposure could be, not where it is. The companion explorer lets you set that line yourself and watch the number move.