Staff Reports
The Centers for Medicare & Medicaid Services has quietly put the American Medical Association’s hold on medical billing codes under a legal microscope. In the Calendar Year 2027 Medicare Physician Fee Schedule proposed rule, CMS inserted a formal Request for Information asking whether the AMA’s control of CPT codes is a monopoly that harms patients and taxpayers. The agency is asking for evidence and ideas — and there’s a short window to speak up.
What CMS specifically asked — and why it matters
CMS asked a blunt question in the Federal Register: “What, if any, evidence is there for CMS to consider regarding the harms or challenges associated with AMA’s monopoly over CPT‑4 licenses for health care entities?” That one line is the heart of the RFI. The agency then listed five topic areas, inviting comments on licensing costs, whether CPT code generation follows a medical‑necessity process, practical alternatives to CPT (like ICD‑10‑PCS or bundled groups), objective governance options to replace or supplement the AMA/RUC process, and pros and cons of alternative payment approaches. CMS frames this as part of the Administration’s “Make America Healthy Again” priorities and a push to base payment on objective cost data rather than exclusive specialty society surveys.
Big stakes for patients, providers and the health system
This isn’t just bureaucratic theater. CPT codes are the language of billing across Medicare and much of the private sector because HIPAA and years of practice made them the de facto standard. If CMS moves from asking questions to changing policy, it could unsettle licensing, copyright, and longstanding industry practice. The AMA reported more than $500 million in annual revenue recently, with royalties surging over the last decade — not exactly chump change when hospitals, EHR vendors, and doctors all must buy or license the code set. Comments on the proposed rule are due by September 14, 2026, under docket CMS‑2026‑2377, and industry groups are already lining up to make their case.
Politics, reform talk, and the players
This RFI sits squarely inside President Donald Trump’s agenda and involves top officials like HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz. Conservative lawmakers such as Rep. Diana Harshbarger and Sen. Bill Cassidy have been calling for AMA transparency and competition for years. Their complaint is simple: a private group writes the codebook, sells copies, and then profits while everyone else has to follow the rules. Call it regulatory capture with a glossy cover and a high price tag.
The next steps are clear. Providers, payers, vendors, and patient advocates should file evidence and ideas with CMS before the comment deadline. Conservatives who want lower costs and less crony control should watch this closely and push for genuine competition, transparency, and accountability. The AMA has made money off the system for decades; now the federal government is asking whether that arrangement still serves patients. If it doesn’t, it’s about time someone stopped pretending the rulebook should be written, sold, and enforced by the same private club.
