Medicare's 2027 Visit Add-On Pays ACO Doctors Twice What Others Get

Starting in January, Medicare will value one add-on to an office visit at 16% for clinicians outside an accountable care organization and at 32% for clinicians in one. The visit code can be identical. The difference is the doctor’s membership.

CMS doesn’t hide why. In the final 2027 physician fee schedule released Nov. 4, the agency agreed with commenters that the proposal “creates a direct financial incentive for clinicians to join and remain in ACOs.” It takes effect Jan. 1.

That sentence sits deep in a 2,468-page rule. For a primary care physician still billing Medicare and wondering about the exit, it may be the most useful one in there.

What changes on the claim

Since 2024, Medicare has paid a flat add-on code, G2211, for visits where the clinician is the continuing focal point of a patient’s care, or is managing a serious or complex condition over time. CMS’s fact sheet says G2211 now becomes modifier B1, worth 16% of the visit.

Modifier B2 is new and worth 32%. Clinicians in Medicare Shared Savings Program ACOs, the LEAD model and ACO PC Flex can use it, and they can bill it for any patient they treat, assigned to the ACO or not. It’s voluntary, and CMS says not every ACO visit qualifies.

CMS’s argument is that being a patient’s focal point while also answering for quality and cost is “inherently more complex” than doing it outside an ACO.

Plenty of people disagreed. The AAFP’s Sept. 11 comment letter said the higher payment “ignores the fact that non-ACO physicians remain accountable for the care they deliver.” It also said ACOs “may not be available to some physicians, such as those practicing in rural areas.” MedPAC warned that a percentage modifier raises patient cost sharing on higher-level visits. CMS’s reply was that billing B2 is optional, and it finalized the modifier as proposed.

What it pays, and the number CMS hasn’t squared

The conversion factor for clinicians who aren’t qualifying alternative payment model participants drops 2.31%, from $33.40 to $32.63. CMS’s selected procedures file shows the national non-facility rate for a level 4 established visit, 99214, falling from $135.61 to $131.17.

Now the add-on. The rule’s impact section says each modifier is set to a percent “of the total RVUs for the E/M service.” But CMS’s modifier file, published so practices can map the change, carries a footnote saying the modifiers increase the work RVU. Its table adds 0.31 to a 99214, not the 0.64 that 16% of 4.02 total RVUs would add.

Those readings produce different money. Here’s a 99214 with its add-on, by DPC Insider’s arithmetic. It uses national rates before geographic adjustment, and G2211’s 0.52 total RVUs at the 2026 factor.

99214 plus add-on	Rule text (total RVUs)	CMS file (work RVUs)
2026 with G2211	about $153	about $153
2027 with B1	about $152	about $141
2027 with B2	about $173	about $151

On the file’s math, even the ACO doctor’s 2027 visit comes in just under what this year’s visit pays. We couldn’t resolve the conflict from CMS’s published documents. Before you budget around 16%, check which number your January remittances show.

Either way, the doctor outside an ACO gets less for this visit than in 2026. The same holds for a 99213, which goes from about $113 with G2211 to about $107 or $99 with B1. One commenter told CMS a percentage would shift value away from the 99213 and 99214 visits that make up most primary care. CMS replied that “there are trade-offs in any system.”

To be fair to the rule, these are per-visit figures. CMS’s specialty table estimates a 1% gain for family practice from RVU changes, against 4% losses for dermatology and 6% for orthopedic surgery, and CMS cautions those are averages. The AAFP’s reaction, as quoted by Chief Healthcare Executive, was blunt: “Physicians will once again begin the year with lower rates as practice costs continue to rise.”

Prospective payment, ACOs first

The rule’s most interesting passages finalize nothing. In a request for information, CMS says it’s “increasingly concerned about the relative undervaluation of primary care services.” It writes that fee-for-service has “inherent limitations as a primary care payment mechanism.”

Any DPC physician could have written those lines. The next step is where the paths split. CMS says it’s interested in developing prospective primary care payment “beginning with the Shared Savings Program,” and that evidence suggests capitation works best “when it is embedded in an accountable care framework.”

The evidence is mixed by CMS’s own account. It says neither Comprehensive Primary Care Plus nor Primary Care First cut total Medicare spending or reached net savings. Commenters strongly endorsed a hybrid primary care payment in the fee schedule, and many wanted it kept distinct from anything done for ACOs. CMS’s answer was one line: “We will consider these comments for future rulemaking.”

Where DPC Fits

The phrase “direct primary care” doesn’t appear in the rule. The modifiers go on Medicare claims, and a DPC doctor who has opted out can’t submit claims outside emergency and urgent care.

The rule lands one step earlier, on the independent physician who still bills Medicare and has started running the numbers. That doctor’s 2027 is a lower conversion factor and an add-on at half the ACO rate, with a clear federal nudge toward joining one. You might read that as a reason to join. You might read it as a reason to stop billing. Both are rational responses to the same incentive.

Medicare and DPC now describe the same problem with visit-based pay, and they answer it differently. CMS says it’s interested in further developing prospective primary care payment, beginning with the Shared Savings Program. The IRS understands that DPC arrangements typically charge a fixed periodic fee. That second route has its own limit, because outside emergency and urgent care, an opted-out practice’s Medicare patients pay under a private contract that Medicare won’t reimburse.

A physician still billing now has 16% and 32% to compare. As of this week, the second number is the one worth weighing.