Xpert Billing Blog

MIPS 2027 Changes: CMS Wants to Drop High Priority Measures

Kara Wily — Mon, 05 Oct 2026 00:00:00 +0000

The MIPS 2027 modifications that CMS announced in July will eliminate the "High Priority" designation and substitute this designation for a list of 78 designated quality measures. In addition to eliminating the High Priority designation, CMS has also removed the Security Risk Analysis (SRA) measure from the Promoting Interoperability category, effective with the 2027 performance period. Although nothing is finalized at this time, CMS closed its comment period on September 14, 2026, and the final rule remains pending.

Chronic Care Management Billing: OIG Audit Checklist

Kara Wily — Fri, 02 Oct 2026 00:00:00 +0000

Beginning with the federal government's watchful eye on chronic care management billing, there will be an audit by the U.S. Department of Health & Human Services Office of Inspector General (HHS OIG), which was officially announced as such on March 16th, 2026. The HHS OIG will audit all Medicare Part B payments made to physicians for chronic care management services, in order to determine if the conditions billed are indeed at least two qualifying chronic conditions.

Reduce Days in A/R When Payers Keep Holding Claims

Kara Wily — Wed, 30 Sep 2026 00:00:00 +0000

The slow pace of payments by payers will delay how long it takes for a payment or deposit after a patient visit. Your staff feels the pain of delayed deposits first. Delayed payments are caused by two different things: payer delays, and internal billing process delays. Of all medical groups polled by MGMA Stat on July 28, 2026; 32% reported an increase in Days in Accounts Receivable (D/A/R) over the last year, while 43% stated D/A/R remained stable during the same time frame.

2025 MIPS Final Score Is Out: Check It Before 2027 Pay

Kara Wily — Mon, 28 Sep 2026 00:00:00 +0000

CMS released your 2025 MIPS results at the end of September 2026. Now it is your MIPS Final Score from 2025 that will determine if every Medicare Part B claim you submit in 2027 will be paid higher than, lower than, or equal to the fee schedule amount. If your MIPS Final Score was less than 75 points, this could result in an adjustment of up to 9% lower payment; if you scored 75 or greater, you will receive an adjustment but the maximum amount of the increase is limited by the need for CMS to maintain budget neutrality.

Podiatry Medicare Reimbursement 2027: APMA Warns of 6% Cut

Kara Wily — Sat, 26 Sep 2026 00:00:00 +0000

Planning for podiatry Medicare reimbursements in 2027 has taken a serious turn. The American Podiatric Medical Association (APMA) formally submitted their comments regarding this issue to the Centers for Medicare & Medicaid Services (CMS) on September 14, 2026. APMA estimates that if CMS adopts its proposed changes to the calendar year 2027 Medicare Physician Fee Schedule as currently written, total podiatric Medicare payments will be reduced by approximately six percent. This number was provided by APMA, not by CMS. While CMS has issued a proposed rule, no action has been finalized at this time.

CMS Ambulatory Specialty Model 2027: Final List Is Out

Kara Wily — Wed, 23 Sep 2026 00:00:00 +0000

Beginning with the announcement of the new CMS Ambulatory Specialty Model (ASM) 2027 as moving into effect, it is a fact that proposals have turned into realities. This was confirmed when CMS announced their list of participating practices for this required Medicare payment model; and, if your practice has heart failure patients and your cardiologists are on this list, you will want to understand how these changes affect your cardiology group. Beginning January 1st, 2027, selected general cardiologists will be subject to payment adjustments based upon the performance of quality, cost, care coordination, and interoperability.

Independent Medical Practice Economics: 2026 Reality Check

Kara Wily — Mon, 21 Sep 2026 00:00:00 +0000

Between January 2018 and January 2026, 152,200 independent physicians were displaced into hospitals or employed by corporations as shown by data from Avalere published by Medical Economics. Most people will tell you this was due to burnout. But I am here to tell you that the true issue is numbers. Today's economic reality for an independent medical practice depends almost entirely upon what type of jobs can be done internally by the practice and those that need to be outsourced and not if there is still some degree of clinical enthusiasm.

8 Revenue Cycle Checkpoints That Stop Medical Billing Denials Early

Kara Wily — Fri, 18 Sep 2026 00:00:00 +0000

Payer denials reached an all-time high in 2026 and medical billing denial prevention is working to prevent the denial from occurring in the first place as opposed to a provider having to pay a biller to pursue the denial. The issue at hand is that instead of focusing on being able to do appeals quicker, the focus needs to be placed on determining when, within the revenue cycle, does the claim break down. Eligibility checks, prior authorizations, documentation requirements, coding issues, claim edit failures and failed submissions each have its own failure point. Determine these failure points and identify who is responsible for each of them; denials become an operational issue which can then be solved rather than continuing to show up as a line item on your accounts receivable aging report.

UnitedHealthcare Prior Authorization Changes: Oct. 1

Kara Wily — Thu, 17 Sep 2026 00:00:00 +0000

Beginning on October 1st 2026, UnitedHealthcare will drop prior authorization for approximately 1700 CPT Codes (approximately 30% of their overall prior authorization) as part of their ongoing efforts to reduce administrative burden. The UnitedHealthcare Prior Authorization Changes are expected to affect all commercial, Medicare Advantage, Community, Individual Exchange and Oxford Plans. They include Cardiology, Oncology, Orthopedics, Imaging, Genetic Testing/Lab Testing, Chiropractic Care and Physical/Occupational Therapy.

2027 OB GYN Billing Changes: One Workflow or Two?

Kara Wily — Wed, 16 Sep 2026 00:00:00 +0000

Your OB-GYN office will have the option of using two maternity billing systems when it enters 2027. New CPT codes go into effect on January 1, 2027, which split maternity care into four separate levels or phases. At the same time, CMS is proposing Medicare-only G-code(s) that would allow for continued use of the bundling system used currently for commercial insurance claims.

Traditional MIPS Is Ending: What Billing Teams Need to Do

Kara Wily — Fri, 11 Sep 2026 00:00:00 +0000

Traditional MIPS reporting has reached its final days. On July 14th, 2026, CMS issued a proposed rule for the CY 2027 Physician Fee Schedule. In that proposed rule was the most significant quality reporting disruption to Medicare quality reporting since MIPS began; the agency plans to sunset traditional MIPS at the end of the 2028 performance period with all eligible clinicians transitioning to MIPS Value Pathways (MVP) by 2029.

2027 Maternity Billing Codes: What Changes Jan. 1

Kara Wily — Thu, 10 Sep 2026 00:00:00 +0000

Beginning on January 1, 2027, the universal maternal coding system your office will bill with is being eliminated. The AMA’s CPT editorial panel has decided to completely revise maternity coding in 2027, taking what was previously a single bundled charge and breaking it down into four separate stages: antepartum (pre-delivery), labor management (during delivery) delivery, and postpartum (after delivery).

2027 ICD-10 Code Changes: What Billing Teams Risk

Kara Wily — Mon, 07 Sep 2026 00:00:00 +0000

October 1, 2026 marks one of the largest changes in ICD-10 billing since last year. The 2027 ICD-10 diagnosis code revisions include approximately 190 new diagnosis codes; deletes approximately 30; and revises approximately 4, as reported by the Centers for Medicare & Medicaid Services (CMS) and Center for Disease Control (CDC), who released their files in June 2026. Many online coding sites have posted the entire list of new ICD-10 codes.

Medicare Advantage Denials: 95% Overturned in 2026

Kara Wily — Fri, 04 Sep 2026 00:00:00 +0000

Reports from the Office of Inspector General (HHS OIG) were published on June 11, 2026. These two reports provide data to support something that billing professionals have likely thought about. Prior authorizations denied by Medicare Advantage for skilled nursing, Long Term Acute Care (LTAC), and in-patient rehabilitation admissions are commonly overturned.

New Federal IDR Gateway Rules Hit Practices Nov. 1

Kara Wily — Wed, 02 Sep 2026 00:00:00 +0000

Medical providers who submit claims for services they provided out-of-network will need to understand a new process by the time winter arrives. On May 28, 2026, CMS finalized a rule outlining how the federal IDR gateway would handle payments for disputed services resulting from the No Surprises Act. As of August 3, 2026, these changes are in place. Those changes that most impact billing personnel relate to disputes where an open negotiation period began on or after November 1, 2026.

CMS Prior Authorization Rules 2026: What to Expect

Kara Wily — Mon, 31 Aug 2026 00:00:00 +0000

If you are seeing quicker turnaround times with your billing team for prior authorization decision approvals from last year, then that is no accident. On Jan. 1, the CMS prior authorization rule for 2026 was enacted as part of the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).

2027 Medicare Physician Fee Schedule: What It Cuts

Kara Wily — Fri, 28 Aug 2026 00:00:00 +0000

The 2027 Medicare Physician Fee Schedule Proposed Rule reduces what physicians are paid by Medicare for each Relative Value Unit (RVU) as well as the way in which billing teams will be required to report Same Day Visits and E/M Coding effective January 1, 2027. On July 14, 2026, CMS issued the Proposed Rule. Comments will close on September 14, 2026.

CMS Wants Feedback on FHIR-Based Quality Reporting by 2030

Kara Wily — Wed, 26 Aug 2026 00:00:00 +0000

CMS is seeking public comment on a proposal to move Quality Payment Program reporting to a FHIR-based, automated data pull from certified EHRs. The RFI outlines a two-year phase-in beginning with the CY 2028 performance year, with mandatory reporting starting in CY 2030. Comments on the proposal close September 14, 2026.

AI Revenue Cycle Management: 63% Adopted, 15% Paid Off

Kara Wily — Mon, 24 Aug 2026 00:00:00 +0000

Sixty-three percent of health care organizations are using artificial intelligence (AI) for their revenue cycle processes. However, only fifteen percent of those organizations have seen a positive ROI as a result. The reason is that most of these organizations purchased the new technology before they were able to establish benchmarks or metrics to measure how well the technology was working.

CMS 2027 MVP Changes Hit All 27 Existing Pathways

Kara Wily — Sat, 22 Aug 2026 00:00:00 +0000

The 2027 Proposed Rule for Medicare Physician Fee Schedule (MPFS) was released by CMS on July 14, 2026. While there are 3 new MIPS Value Pathways (MVP), the real story here is what will happen to the existing 27. CMS intends to revise each of those pathways prior to opening the reporting period in 2027. So if your practice has already selected an MVP pathway and established a process around it, that process is going to be changing.

Federal Court Blocks 8 Provisions of the 2027 ACA Marketplace Rule

Kara Wily — Wed, 19 Aug 2026 00:00:00 +0000

Federal District Court in Maryland has temporarily blocked eight components of a new CMS Marketplace Rule (the "Rule") that was scheduled to go into place on July 20, 2027. This temporary injunction was issued by the U.S. District Court in Maryland on July 16, 2027; which is 4 days prior to when the components of the Rule were to take effect. The injunction will alter the way marketplaces process eligibility determinations, enrollments and product design for the 2027 year. If you are a provider with an active billing office supporting patients purchasing plans through the Exchange, this ruling impacts many aspects of the pre-enrollment verification processes, patient subsidy eligibility and networks, some or all of which you may have previously incorporated into existing workflow(s) within your practice.

Medicaid Work Requirements Deadline: What Billing Teams Must Track Now

Kara Wily — Tue, 18 Aug 2026 00:00:00 +0000

CMS’s interim final rule on Medicaid work requirements will take effect July 31, 2026. The deadline for state enrollees to receive notice about the new Medicaid work requirements is August 31, 2026. This new rule requires all adults aged 19-64 in the 41 Medicaid Expansion states (and Washington D.C.) to document at least 80 hours per month of paid employment, education, volunteerism, or any combination thereof, beginning January 1, 2027.

19 New HCPCS Codes Hit Home Health Billing Oct. 1, 2026

Kara Wily — Fri, 14 Aug 2026 00:00:00 +0000

Beginning October 1, 2026, CMS is adding 19 new HCPCS codes to the "non-routine supplies" section of the Home Health Consolidated Billing list under Change Request 14510. Home health agencies and DME suppliers billing for syringes, catheters, ostomy supplies, incontinence inserts, and wound care tape will need to update edit lists, verify active home health episodes, and route claims to the primary HHA before the effective date to avoid denials.

SNF VBP FY 2027: Your August Report Sets the Payment Rate

Kara Wily — Thu, 13 Aug 2026 00:00:00 +0000

CMS has published FY 2027 SNF Value-Based Purchasing performance score reports in iQIES, and they now score facilities against 8 quality measures instead of 4. The incentive payment multiplier in your report determines what CMS pays on every Part A claim for the fiscal year, and corrections are due to the SNF VBP Help Desk no later than August 30, 2026. Billing and revenue cycle teams should pull the report now, compare baseline and performance period data against internal MDS and payroll records, and flag any discrepancy well before the deadline closes.

FY 2027 Post-Acute Payment Rules: October 1 Cutover

Kara Wily — Tue, 11 Aug 2026 00:00:00 +0000

The CMS has approved four post-acute care (PAC) rule finalizations that were released late July 2026 with each effective October 1, 2026. The finalizations are part of the FY 2027 PAC payment update and apply to Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Inpatient Psychiatric Facilities (IPF), and Hospice. The rate increase will be 2.3% to 2.4%, depending upon the type of facility. The real issue is found in the policy language, however. For example, Hospices will need to provide an election statement addendum to each beneficiary who elects this coverage as opposed to only providing it when asked by the beneficiary. Additionally, Inpatient Rehabilitations Facilities will have to meet a harder deadline to begin therapy for beneficiaries after discharge from hospitals; also, they will need to conduct their first interdisciplinary team meetings within 5 days of hospital discharge. Therefore, billing teams for all these providers will need approximately 7 weeks to correct or amend any claims edit, form corrections, and/or workflow issues prior to the end of the fiscal year.

AMA Adds 58 New Category III CPT Codes for 2027

Kara Wily — Wed, 05 Aug 2026 00:00:00 +0000

Billing teams have a new set of codes to work with in their planning. In total there are 58 additional 2027 Category III cpt codes; in addition, there will be revised language for three (3) previously-existing codes. Approval by the american medical association was made as part of the cpt editorial panel meeting in february, 2026; however, these new additions will become effective on January 1, 2027 and will include an initial six-month "lead-in" period that begins on July 1, 2026.

CMS Medicaid Provider Tax Rule Cuts $246B What It Means

Kara Wily — Mon, 03 Aug 2026 00:00:00 +0000

CMS has proposed the largest adjustment to Medicaid financing since Medicaid was created. On July 21, 2026, the Agency for Healthcare Research and Quality (AHRQ) issued a proposal for the Medicaid Provider Tax Rule (CMS-2452-P). In this new proposal, CMS is replacing the current 6% limit that has been in place since January 1999 as a "hold harmless" or "cap," with state-by-state limits that are based on what each state had in place on July 4, 2025. The AHRQ estimates the rule would save the federal government $246 billion from 2026 through 2035. That savings will come out of state Medicaid budgets; state Medicaid budgets fund all of the claims paid under the program. Comments on the rule are due by September 21, 2026.

CMS's New No Surprises Act Remittance Codes Explained

Kara Wily — Tue, 28 Jul 2026 00:00:00 +0000

The billing teams have another date to include in their planning. CMS has given its guidance on the use of No Surprises Act remittance codes by group health plans and insurers as of July 17, 2026, which will require the use of these remittance codes on the remittance advices for out-of-network claims effective January 1, 2027. The new guidance is based on the requirements stated within the final rule for Independent Dispute Resolution Operations that was issued by CMS on July 17, 2026. As an office who submits or posts out-of-network claims, it may affect how you process those payments in 2027.

CMS Names 29 Early Adopters for Electronic Prior Authorization Before 2027

Kara Wily — Sun, 18 May 2026 00:00:00 +0000

Beginning with the announcement by CMS of 29 healthcare organizations as "Early Adopters" under the Electronic Prior Authorization Acceleration Initiative, the organization is working on a cross-sector collaboration model involving a combination of health systems, EHR developers, physician practices, and digital-health companies to identify workflow challenges and technology issues that will need to be resolved before the electronic prior authorization requirements take effect in January 2027.

Medicaid Noncitizen Funding Ends Oct. 1: What Providers Must Do Now

Kara Wily — Wed, 07 May 2026 00:00:00 +0000

On April 8th, 2026, CMS issued State Health Official letter SHO #26-001 to instruct state agencies to discontinue claiming federal Medicaid & CHIP matching monies for all lawfully present noncitizens, effective October 1, 2026. This directive was enacted under Section 71109 of the Working Families Tax Cut legislation (Public Law 119-21). Refugees, asylees, parolees, trafficking victims, etc. (non-citizens) that are receiving full Medicaid coverage NOW will LOSE federal funding eligibility within six months.

NCCI Q3 2026 Add-On Code Edits: What Changes July 1

Kara Wily — Tue, 05 May 2026 00:00:00 +0000

CMS released the Q3 2026 version of the NCCI Add-on Codes (AOC) edit update on April 20, 2026. This edit is scheduled for implementation on July 1, 2026. The NCCI AOCs determine which add-on procedures can be billed in conjunction with primary services under Medicare Part B. Any changes to these pairs may result in CO-97 denial if the claims scrubber has not been updated.

EHR vs EMR: Why the Difference Affects Your Billing

Kara Wily — Tue, 29 Apr 2026 00:00:00 +0000

Most healthcare providers treat EHR and EMR as the same term, yet they are not the same. That confusion can have very real billing implications. An Electronic Medical Record (EMR) is a digitized version of an individual provider's paper medical record - valuable to that provider within their own clinical setting but unable to be accessed by other providers outside of that environment.

HETS EDI Attestation Due May 11: No Attestation, No Eligibility

Kara Wily — Fri, 24 Apr 2026 00:00:00 +0000

As a provider using a clearinghouse or vendor for Medicare eligibility verification, you have a firm deadline looming. On May 11, 2026, CMS plans to roll out a new HETS trading partner management system, and all providers must be enrolled in the system by submitting a HETS EDI enrollment attestation prior to that date.

Q2 2026 HCPCS Update: 36 New Codes Billers Must Know Now

Kara Wily — Thu, 23 Apr 2026 00:00:00 +0000

The Q2 2026 HCPCS Level II update adds 36 new codes, 17 PLA codes, and 6 sleep apnea C-codes effective April 1, 2026. Learn what changed and what your billing team must do now to avoid claim errors and payment delays from outdated coding.

CMS Anti-Fraud CRUSH Rule Puts Every Biller at Risk

Kara Wily — Wed, 22 Apr 2026 00:00:00 +0000

CMS's CRUSH initiative is already revoking billing privileges and suspending payments. CRUSH — Comprehensive Regulations To Uncover Suspicious Healthcare — represents the largest CMS anti-fraud enforcement action to date, with 5,586 providers revoked and $5.7 billion in payments suspended in 2025 alone. Learn what the CRUSH rule means for your practice and what to do now.

Medicaid Provider Tax Rule 2026: Get Ready for April 3 Deadline

Kara Wily — Fri, 13 Mar 2026 00:00:00 +0000

CMS finalized the Medicaid provider tax rule effective April 3, 2026. Learn what billing teams in affected states must do before compliance deadlines. Discover how the closure of the Medicaid MCO tax loophole impacts reimbursement rates, state-directed payments, and RCM strategies in seven key states.

2026 Telehealth: Virtual Direct Supervision Now Permanent

Kara Wily — Tue, 10 Mar 2026 00:00:00 +0000

CMS made virtual direct supervision in telehealth permanent in the 2026 MPFS. Learn the new billing and compliance rules to protect your practice revenue. Discover why the permanent removal of frequency limits in facilities and the formalization of virtual "immediately available" standards fundamentally alter telehealth operations.

RCM Vendor Cybersecurity Audits: 2026 HIPAA Requirements

Kara Wily — Thu, 05 Mar 2026 00:00:00 +0000

2026 HIPAA updates mandate RCM vendor security verification. Discover why HITRUST and SOC 2 Type II certifications protect your practice. Learn why mandatory multi-factor authentication, end-to-end encryption, and 24-hour breach notifications are now essential for healthcare provider compliance.

The End of Paper CLIA: Mandatory Digital Shifts in 2026

Kara Wily — Mon, 02 Mar 2026 00:00:00 +0000

CMS ends paper CLIA on March 1, 2026. Use our guide to update Form CMS-116 and Pay.gov to avoid technical denials. Protect your lab revenue today. Discover why this mandatory transition to digital-only CLIA management creates immediate operational risks for laboratories and how to navigate the 5-step transition roadmap.

Top 10 Revenue Cycle Management (RCM) Companies in Healthcare (2026)

Kara Wily — Wed, 25 Feb 2026 00:00:00 +0000

Stop losing 12% to denials. Compare the top 10 RCM companies of 2026. See why Human Medical Billing wins with less than 2% denial rates. Discover which RCM partner wins in 2026 based on denial rates, staff access, and contract terms.

Medicare Advantage Enrollment 2026: SNP & Billing Guide

Kara Wily — Tue, 24 Feb 2026 00:00:00 +0000

Analyze Medicare Advantage Enrollment 2026. See why SNPs are growing, how major carriers shifted, and 3 billing tips for V28 risk adjustment. Discover why major insurers are focusing on higher acuity SNP plans with richer risk-adjusted payment rates and more direct care management opportunities.

What is POS 11 in Medical Billing? A Guide for Practices

Kara Wily — Fri, 13 Feb 2026 00:00:00 +0000

Understand POS 11 in medical billing and how it impacts your reimbursement. Learn the differences between POS 11, 22, 21, and telehealth rules. Discover why this two-digit code is essential for identifying services provided in a physician's office versus a hospital setting and how it affects professional fee rates.

New PBM Transparency Requirements 2026: The Audit Guide

Kara Wily — Thu, 05 Feb 2026 00:00:00 +0000

Master the 2026 PBM transparency requirements. Learn how EBSA rules impact ERISA plans, expose hidden fees, & empower audits. Discover how these new Department of Labor mandates aim to reduce costs for self-insured employers and patients by "turning the light on" in the pharmaceutical supply chain.

Medicare 2026: Survival Guide for Private Practices & Hospitals

Kara Wily — Thu, 22 Jan 2026 00:00:00 +0000

Medicare 2026 costs are up. See new Part B rates ($202.90) and permanent telehealth rules. Our billing guide helps solo and group practices protect cash flow from increased patient responsibility.

Expert Author: Kara Wily, RCM Expert.

2026 Payer Squeeze: Fed Rates & Medical Practice Revenue

Kara Wily — Tue, 20 Jan 2026 00:00:00 +0000

Fed rate cuts in 2026 will lower insurer profits, leading to strict audits and denials. Learn how to protect your medical practice revenue from the squeeze.

Expert Author: Kara Wily, RCM Expert.

CMS DMEPOS Master List Update 2026: New Billing Rules

Kara Wily — Wed, 14 Jan 2026 00:00:00 +0000

CMS-6097-N expands the DMEPOS Required List. See which items need Face-to-Face encounters & Standard Written Orders (WOPD) by April 13, 2026 to prevent payment denials.

Expert Author: Kara Wily, RCM Expert.

Top 5 Medical Billing Companies in USA | (2026 Review)

Kara Wily — Tue, 13 Jan 2026 00:00:00 +0000

We reviewed the best medical billing companies in 2026. Compare top 5 firms on denial rates, fees, & contracts to find winner for your practice. Discover why human oversight beats software bots.

Expert Author: Kara Wily, RCM Expert.

PBM Spread Pricing Ban 2026: End of Hidden Pharmacy Costs?

Kara Wily — Tue, 06 Jan 2026 00:00:00 +0000

New 2026 laws ban PBM spread pricing in key states like California. Learn how SB 41 and Medicaid reforms impact your medical billing and revenue cycle.

Expert Author: Kara Wily, RCM Expert.

The 2026 Medicare Advantage Shift: Why Denials Will Spike

Kara Wily — Wed, 31 Dec 2025 00:00:00 +0000

The 2026 Great Retreat left 2.9M seniors in limbo. Learn why Medicare Advantage denials are rising and how strict eligibility checks protect your cash flow.

Expert Author: Kara Wily, RCM Expert.

What Is Denial in Medical Billing? Your Guide to Getting Paid Faster

Kara Wily — Mon, 29 Dec 2025 00:00:00 +0000

Understand what is denial in medical billing and how to fix it. Discover causes and proven strategies to recover revenue. Improve your practice's bottom line.

Expert Author: Kara Wily, Head of Business Development at Human Medical Billing. 23+ Years in U.S. Medical Billing and RCM Expert.

New CMS Drug Pricing Models 2026: GLOBE & GUARD Explained

Kara Wily — Fri, 26 Dec 2025 00:00:00 +0000

CMS released the GLOBE and GUARD models December. See how these mandatory updates impact Medicare Part B & D reimbursement and billing in 2026.

Expert Author: Kara Wily, RCM Expert.

Medicare 2026 Skin Substitute Update: New Coverage & Billing

Kara Wily — Thu, 18 Dec 2025 00:00:00 +0000

Stay ahead of the Medicare 2026 Skin Substitute Update. Learn about the $127.14 flat rate, the 18 covered products, and vital LCD coding changes for 2026.

Expert Author: Kara Wily, RCM Expert.

CPT 92960: Cardioversion Coding & Billing Guide [2026]

Kara Wily — Wed, 17 Dec 2025 00:00:00 +0000

Updated for 2026: Master CPT code 92960. Get the latest RVUs, correct modifiers, ICD-10 crosswalks, and denial prevention tips for cardioversion procedures.

Expert Author: Kara Wily, RCM Expert.

2026 Short-Duration RPM Codes: The 16-Day Rule is Dead

Kara Wily — Mon, 15 Dec 2025 00:00:00 +0000

The 16-day rule is dead. New 2026 RPM codes finally allow billing for 2-15 days. Stop losing revenue on acute care - get the new rules here.

Expert Author: Kara Wily, RCM Expert.

CMS Updates LCDS Version 5.1 & New Fall Injury Coding for 2026

Kara Wily — Wed, 10 Dec 2025 00:00:00 +0000

Effective Jan 1, 2026, the CMS LCDS Version 5.1 Errata updates J1900 definitions for falls with major injury. Learn the rules to secure LTCH QRP compliance.

Expert Author: Kara Wily, RCM Expert.

Medicare Inpatient-Only List Ends: 2026 CMS Rule & Impact

Kara Wily — Fri, 28 Nov 2025 00:00:00 +0000

CMS ends the Medicare Inpatient-Only List starting 2026. See which 285 codes change first, the 2028 timeline, and how to prevent billing denials now.

Expert Author: Kara Wily, RCM Expert.

What is PCN on Insurance Card?

Kara Wily — Fri, 21 Nov 2025 00:00:00 +0000

Struggling with pharmacy denials? It might be your PCN code. Learn exactly what this number does, where to find it, and how to fix claim errors quickly.

Expert Author: Kara Wily, RCM Expert.

ACA Subsidy Extension: Will 2026 Premiums Explode?

Kara Wily — Wed, 19 Nov 2025 00:00:00 +0000

Will ACA subsidy extension pass? Learn how the 2025 deadline impacts 2026 health insurance premiums, open enrollment, & patient costs in our expert guide.

Expert Author: Kara Wily, RCM Expert.

What Is Credentialing in Medical Billing? A Complete Guide 2025

Kara Wily — Mon, 17 Nov 2025 00:00:00 +0000

It's the process that gets you paid. This 2025 guide details the steps, how to prevent costly claim denials, & the critical credentialing vs. enrollment differences.

Expert Author: Kara Wily, RCM Expert.

Is Insurer Downcoding Legal? A 2025 State Law Guide

Kara Wily — Fri, 14 Nov 2025 00:00:00 +0000

New 2025 state laws in Arkansas, Virginia, & Ohio are fighting back against AI downcoding. Read full state-by-state guide & learn how to protect your practice.

Expert Author: Kara Wily, RCM Expert.

2026 PFS 2.5% Efficiency Adjustment: Stealth Cut for Specialists

Kara Wily — Tue, 11 Nov 2025 00:00:00 +0000

The 2026 PFS final rule adds a 2.5% efficiency adjustment, a stealth pay cut for procedural medicine. See how this RVU cut erases the 3.26% pay raise.

Expert Author: Kara Wily, RCM Expert.

Why Paying for Patient Financial Experience Is the New Competitive Edge for Small Medical Practices

Kara Wily — Thu, 06 Nov 2025 00:00:00 +0000

Clear billing, flexible payment plans, and digital payment options help small practices boost collections, reduce write-offs, and improve patient trust.

Expert Author: Kara Wily, RCM Expert.

Healthcare M&A in Q3 2025: How 367 Physician Deals Hit Billing

Kara Wily — Fri, 31 Oct 2025 00:00:00 +0000

Q3 2025 record M&A surge saw 367 physician deals. Learn how this wave, driven by PE & value-based care, impacts medical billing, & coding.

Expert Author: Kara Wily, RCM Expert.

104-Minute Rule: Medicare vs CPT Critical Care Billing (2025)

Kara Wily — Thu, 30 Oct 2025 00:00:00 +0000

Guide to Medicare's 104-Minute Rule for critical care. Learn why CMS needs 104 min to bill 99292, not CPT's 75 min. Avoid compliance risks & revenue loss.

Expert Author: Kara Wily, RCM Expert.

Why Private Equity is Targeting Outpatient Cardiology

Kara Wily — Thu, 16 Oct 2025 00:00:00 +0000

PE is targeting outpatient cardiology. Learn to manage deal risks, boost revenue, and secure your independence with optimized medical billing.

Expert Author: Kara Wily, RCM Expert.

Medicare Physician Fee Schedule Quarterly Update: What Providers Need to Know

Kara Wily — Tue, 14 Oct 2025 00:00:00 +0000

Discover the Medicare Physician Fee Schedule October 2025 update. Learn new CPT/HCPCS codes, updated payments, & smart denial reduction strategies.

Expert Author: Kara Wily, RCM Expert.

How to Choose the Best Medical Billing Company: The Complete Guide for Healthcare Providers

Kara Wily — Wed, 08 Oct 2025 00:00:00 +0000

Learn how to choose the best medical billing company. Compare costs, expertise, technology, and compliance to avoid common errors and boost revenue.

Expert Author: Kara Wily, RCM Expert.

Medicare Advantage Plans 2026: Complete Guide to Changes, Costs, and How to Choose the Best Plan

Kara Wily — Fri, 03 Oct 2025 00:00:00 +0000

Discover Medicare Advantage plans 2026 updates, market changes, costs, and how to find the best plan. Learn tips for enrollment and billing.

Expert Author: Kara Wily, RCM Expert.

Healthcare AI Adoption 2025: Providers Report 81% Revenue Surge

Kara Wily — Tue, 30 Sep 2025 00:00:00 +0000

Discover how healthcare AI adoption 2025 delivers 81% revenue lifts, cuts costs, and boosts patient care. Learn proven AI-driven strategies and next steps.

Expert Author: Kara Wily, RCM Expert.

UnitedHealthcare Medicare Advantage Referral Requirements 2026 Guide

Kara Wily — Fri, 26 Sep 2025 00:00:00 +0000

Learn about UnitedHealthcare Medicare Advantage referral requirements for 2026. Find out who needs referrals, which plans are exempt, timelines, and billing rules.

Expert Author: Kara Wily, RCM Expert.

AHA Coding Clinic Q3 2025: What Healthcare Providers and Billing Teams Need to Know Now

Kara Wily — Wed, 24 Sep 2025 00:00:00 +0000

Learn about 28 ICD-10-CM/PCS coding updates covering presymptomatic Type 1 diabetes, BMI coding, pulmonary embolism, pancytopenia, & CEU webinar.

Expert Author: Kara Wily, RCM Expert.

Medicaid Spending Cuts Impact Pediatric Care: America’s Hidden Healthcare Crisis

Kara Wily — Mon, 22 Sep 2025 00:00:00 +0000

Explore how proposed Medicaid funding cuts put pediatric healthcare of U.S. children at risk. Learn about access, provider impacts, and adaptation strategies.

Expert Author: Kara Wily, RCM Expert.

2025 Internal Medicine Billing Trends: Guide by Human Medical

Kara Wily — Tue, 16 Sep 2025 00:00:00 +0000

Discover key 2025 internal medicine billing trends including MIPS updates, chronic care management audits, denial prevention, AI & coding best practices.

Expert Author: Kara Wily, RCM Expert.

The Critical Role of HCC Coding in Healthcare Today

Kara Wily — Mon, 15 Sep 2025 00:00:00 +0000

Discover why HCC coding is essential for accurate reimbursement and quality care. Learn best practices, audit tips, and how we supports your coding success.

Expert Author: Kara Wily, RCM Expert.

2025 CMS Physician Self-Referral Code Updates: (CPT/HCPCS)

Kara Wily — Fri, 12 Sep 2025 00:00:00 +0000

Discover 2025 CMS Physician Self-Referral CPT/HCPCS updates: 130 code additions, 23 deletions, & ESRD drug updates for compliance.

Expert Author: Kara Wily, RCM Expert.

CMS Delays Medicare Advantage Unused Benefits Policy: Impact on Healthcare Providers

Kara Wily — Wed, 10 Sep 2025 00:00:00 +0000

CMS has delayed its mid-year alerts for unused supplemental benefits, giving Medicare Advantage plans more time to set up tracking, communication systems.

Expert Author: Kara Wily, RCM Expert.

What is Revenue Cycle Management? | Complete RCM Guide

Kara Wily — Tue, 09 Sep 2025 00:00:00 +0000

Explore the fundamentals of revenue cycle management in healthcare. Understand each step of the RCM, common challenges, & the impact of technology.

Expert Author: Kara Wily, RCM Expert.

CMS Expands Access to Catastrophic Health Insurance Plans Starting 2026

Kara Wily — Fri, 05 Sep 2025 00:00:00 +0000

CMS expands catastrophic health plan access in 2026. Find out how providers can prepare for changes in billing, eligibility, and revenue cycle management.

Expert Author: Kara Wily, RCM Expert.

Cigna's New E/M Downcoding Reimbursement Policy: Oct 2025

Kara Wily — Wed, 03 Sep 2025 00:00:00 +0000

Learn how Cigna’s new E/M downcoding policy starting October 2025 impacts CPT codes and reimbursements. Discover steps to protect revenue.

Expert Author: Kara Wily, RCM Expert.

What is Medical Coding?

Kara Wily — Mon, 01 Sep 2025 00:00:00 +0000

Learn what medical coding is, why it matters in healthcare, & how coders use ICD-10, CPT, & HCPCS codes. Explore key roles, certifications, & future trends.

Expert Author: Kara Wily, RCM Expert.

Medical Billing Services Cost California (2025)

Kara Wily — Fri, 29 Aug 2025 00:00:00 +0000

Learn key factors in California billing costs: staffing, payer mix, denials, and AI. See 2025 trends & how the right partner cuts expenses & ensures compliance.

Expert Author: Kara Wily, RCM Expert.

What is Medical Billing?

Kara Wily — Thu, 28 Aug 2025 00:00:00 +0000

Learn what medical billing is, why it matters, the billing cycle, common challenges, and how AI is transforming healthcare billing for accuracy and efficiency.

Expert Author: Kara Wily, RCM Expert.

How Cutting After-Hours Charting Helps Reduce EHR Time for Doctors

Kara Wily — Tue, 26 Aug 2025 00:00:00 +0000

Discover how reducing after-hours EHR charting helps doctors save time, cut burnout, and improve workflow efficiency. do this 30/60/90-day roadmap.

Expert Author: Kara Wily, RCM Expert.

Essential Medical Billing KPIs for 2025 for Revenue Cycle Profit

Kara Wily — Fri, 22 Aug 2025 00:00:00 +0000

Learn the key medical billing KPIs for 2025 - days in A/R, clean claim rate, denial rate, and net collection rate that drive cash flow and revenue cycle growth.

Expert Author: Kara Wily, RCM Expert.

How AI and Automation Are Revolutionizing Medical Billing Processes in 2025

Kara Wily — Thu, 21 Aug 2025 00:00:00 +0000

See why medical billing needed change, how AI and automation improve revenue cycles in 2025, with benefits, trends, adoption steps, and future outlook.

Expert Author: Kara Wily, RCM Expert.

CMS WISeR Model: Medicare’s AI-Powered Prior Authorization Test to Cut Waste in 2025

Kara Wily — Wed, 20 Aug 2025 00:00:00 +0000

In 2025, Medicare’s new AI-driven prior authorization test aims to cut wasteful spending, improve billing efficiency, and ease provider and patient challenges.

Expert Author: Kara Wily, RCM Expert.

US Medical Billing 2025: Fees, Prior Auth, NSA, and Practical RCM Playbook

Kara Wily — Sat, 16 Aug 2025 00:00:00 +0000

US medical billing 2025 explained: fee schedule updates, CPT code changes, prior authorization rules, IDR issues, and a proven RCM playbook for providers.

Expert Author: Kara Wily, RCM Expert.

Medicare Advantage Home Visit Diagnosis Reforms: What Doctors Must Know in 2025

Kara Wily — Thu, 14 Aug 2025 00:00:00 +0000

Dive into 2025 Medicare Advantage reform essentials - policy updates, telehealth tips, and billing strategies for compliance. FAQs included.

Expert Author: Kara Wily, RCM Expert.

How Medical Billing Services Protect Against Medicaid Cuts

Kara Wily — Thu, 12 Jun 2025 00:00:00 +0000

Learn how medical billing services help protect your practice from Medicaid cuts through cost savings and expert denial management.

Expert Author: Kara Wily, RCM Expert.

Medicare Advantage Denials Threaten Revenue in 2025

Kara Wily — Mon, 09 Jun 2025 00:00:00 +0000

In 2025, Medicare Advantage denials are surging-fueling revenue loss and care delays. This growing crisis is straining RCM for U.S. providers.

Expert Author: Kara Wily, RCM Expert.

Avoid No Surprises Act Penalties: Mid-Year 2025 Update

Kara Wily — Fri, 06 Jun 2025 00:00:00 +0000

Learn how to stay compliant with the No Surprises Act in mid-2025. Avoid costly penalties with QPA, IDR, GFE, and gag clause enforcement tips.

Expert Author: Kara Wily, RCM Expert.

$68 Billion Lost: Why In-House Billing Must Go

Kara Wily — Wed, 21 May 2025 00:00:00 +0000

Hospitals lost $68 billion due to billing errors. Learn why in-house billing is failing and how outsourcing helps save money and reduce risks.

Expert Author: Kara Wily, RCM Expert.

The Trends Set to Reshape Behavioral Health Billing in 2025

Kara Wily — Wed, 21 May 2025 00:00:00 +0000

Here are the key trends in behavioral health billing, new CPT/HCPCS codes (G0560, G0553), telehealth policies & Medicare updates.2025

Expert Author: Kara Wily, RCM Expert.

Q3 2025 PLA Code Updates: 23 New AMA Lab Tests to Know

Kara Wily — Thu, 15 May 2025 00:00:00 +0000

23 new PLA codes are now live for Q3 2025. See what AMA added, what got deleted, and how these updates impact billing. Stay compliant.

Expert Author: Kara Wily, RCM Expert.

What’s Changing in Medicaid under the 2025 Reconciliation Bill?

Kara Wily — Tue, 13 May 2025 00:00:00 +0000

The 2025 Reconciliation Bill could reshape Medicaid with caps on extra payments, frozen provider taxes potentially affecting millions - learn how

Expert Author: Kara Wily, RCM Expert.

MIPS 2025 Timeline: Deadlines You Can’t Afford to Miss

Kara Wily — Mon, 12 May 2025 00:00:00 +0000

Master the MIPS 2025 reporting timeline - key dates from Oct 1 2024 virtual-group kickoff to Mar 31 2026 submission.

Expert Author: Kara Wily, RCM Expert.

Medical Credentialing in 2025: New NCQA Rules You Must Know

Kara Wily — Thu, 08 May 2025 00:00:00 +0000

Discover how Medical Credentialing in 2025 is changing with new NCQA standards, monthly monitoring, & federal compliance updates don’t risk falling behind.

Expert Author: Kara Wily, RCM Expert.

Value-Based Care in 2025: Lifeline or Liability for Your Practice?

Kara Wily — Mon, 05 May 2025 00:00:00 +0000

Explore Value-Based Care in 2025. Learn how to manage financial impacts, opportunities, and strategies for your practice’s success.

Expert Author: Kara Wily, RCM Expert.

2025 HIPAA Security Rule: Final Warning for Private Practices

Kara Wily — Fri, 25 Apr 2025 00:00:00 +0000

The 2025 HIPAA Security Rule is here. MFA, encryption, & annual risk reviews are now mandatory. Is your private practice ready? Learn how to stay compliant.

Expert Author: Kara Wily, RCM Expert.

July 2025 HCPCS Update: These Codes will Cost You a lot!

Kara Wily — Thu, 24 Apr 2025 00:00:00 +0000

July 2025 HCPCS code changes are here. Some are new, some gone, and some updated. Get ready now to avoid billing mistakes.

Expert Author: Kara Wily, RCM Expert.

Out-of-Network Billing in 2025: What Doctor Needs to Know

Kara Wily — Fri, 04 Apr 2025 00:00:00 +0000

Stay ahead in 2025 with this guide to out-of-network billing. Learn key steps, legal insights, better rates, and how to manage OON claims effectively.

Expert Author: Kara Wily, RCM Expert.

Future of Telehealth at Risk? Deadline Extended Until September 2025

Kara Wily — Thu, 20 Mar 2025 00:00:00 +0000

The Medicare telehealth extension is now until September 2025. Learn what’s changing, how it impacts providers, and what the future holds for virtual care.

Expert Author: Kara Wily, RCM Expert.

Doctors vs. Private Equity – Healthcare legislation 2025 Explained

Kara Wily — Wed, 19 Mar 2025 00:00:00 +0000

Get the latest updates on U.S. healthcare legislation for 2025, including Massachusetts HB 5159, California SB 351 & AB 1415, and Texas HB 2747 & SB 1595.

Expert Author: Kara Wily, RCM Expert.

Medical Billing for Multi-Specialty Practices – 5 Must-Know Hacks

Kara Wily — Tue, 25 Feb 2025 00:00:00 +0000

Tackle complex reimbursement, compliance, and coding quickly. Discover 5 expert strategies to simplify billing in your multi-specialty practice. Don't miss out.

Expert Author: Kara Wily, RCM Expert.

Medical Billing vs. Medical Coding: What’s the Difference?

Kara Wily — Fri, 14 Feb 2025 00:00:00 +0000

Discover the key differences between medical billing and medical coding, their responsibilities, career paths, salaries, and certifications.

Expert Author: Kara Wily, RCM Expert.

Denial Prevention Checklist: First-Time Approval Guaranteed!

Kara Wily — Wed, 12 Feb 2025 00:00:00 +0000

Discover a proven denial prevention checklist to secure first-time claim approvals, reduce revenue loss, and enhance efficiency in medical billing.

Expert Author: Kara Wily, RCM Expert.

A New Overpayment Rule – CMS Changes the 60-Day Rule

Kara Wily — Fri, 07 Feb 2025 00:00:00 +0000

Learn about the New Overpayment Rule and CMS's 60-Day Rule changes. Discover compliance requirements, penalties, and best practices.

Expert Author: Kara Wily, RCM Expert.

Medical Billing Services: What No One Tells You in 2025!

Kara Wily — Thu, 06 Feb 2025 00:00:00 +0000

Facts about medical billing services in 2025! Discover hidden pitfalls, cost-saving secrets, and expert tips to boost revenue and stay compliant.

Expert Author: Kara Wily, RCM Expert.

The Role of Medical Billing in Revenue Cycle Management

Kara Wily — Fri, 31 Jan 2025 00:00:00 +0000

Discover the 10 steps of the medical billing revenue cycle, why it's vital to RCM, and tips to prevent billing issues. Read now!

Expert Author: Kara Wily, RCM Expert.

Top Medical Billing Trends to Watch in 2025

Kara Wily — Mon, 27 Jan 2025 00:00:00 +0000

Explore 2025's key medical billing trends, from AI and patient-centric billing to telehealth and cybersecurity. Stay ahead with practical tips.

Expert Author: Kara Wily, RCM Expert.

Medical Billing Challenges in California and How to Overcome Them

Kara Wily — Tue, 21 Jan 2025 00:00:00 +0000

Explore the unique medical billing challenges in California and find actionable strategies to streamline your billing processes.

Expert Author: Kara Wily, RCM Expert.

12 Benefits of Outsourcing Medical Billing Services for Providers

Kara Wily — Wed, 11 Dec 2024 00:00:00 +0000

Discover how outsourcing medical billing services can save money, reduce errors, improve cash flow, and enhance patient care.

Expert Author: Kara Wily, RCM Expert.

Human Medical Billing Helps Healthcare Providers Avoid MIPS (Medicare) Payment Penalties

Kara Wily — Tue, 22 Oct 2024 00:00:00 +0000

Simplify MIPS reporting and avoid penalties. Human Medical Billing offers expert help and streamlined processes.

Expert Author: Kara Wily, RCM Expert.

How Outsourcing Medical Billing Services Can Boost Your Practice’s Revenue

Kara Wily — Wed, 16 Oct 2024 00:00:00 +0000

Learn how to improve efficiency and enhance patient care. Discover the benefits, compare it to in-house billing, and find the right outsourcing partner.

Expert Author: Kara Wily, RCM Expert.