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Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
WISeR Prior Authorization Starts in Six States: What to Submit, When and to Whom
Traditional Medicare now requires prior authorization for a list of services in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Requests are accepted from January 5 and apply to dates of service on or after January 15. Here is the practical setup.
Payer Changes for 2026: Cigna Downcoding, Prior Auth Pledges and MA Plan Exits
Cigna paused its automatic E/M downcoding policy days before its October 1 start, but it is not dead. Insurers promised prior authorization changes by January 1, 2026, and UnitedHealthcare, Humana and Aetna are leaving counties for 2026. Here is what each change means in the billing office.
Summer 2025 Payer Policy Roundup: Cigna Downcoding, the AHIP Pledge and HIPAA
Between June and September 2025 insurers promised to cut prior authorization, Cigna announced an E/M downcoding policy effective October 1, CMS closed comments on two payment rules, and the HIPAA Security Rule stayed proposed. Here is what changed, what did not, and what to do before October.
The WISeR Model: Prior Authorization Comes to Traditional Medicare in Six States
CMS announced the WISeR model on June 27, 2025. Starting January 1, 2026, certain services in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington will need prior authorization or face pre-payment review in traditional Medicare. Here is how it works and how to prepare.
The June 23 Prior Authorization Pledge: What Changes in 2026 and 2027
On June 23, 2025, health insurers covering about 257 million Americans committed through AHIP and HHS to simplify prior authorization, with deadlines in 2026 and 2027. Here is what was promised, how it lines up with the CMS rule already on the books, and how to design your workflow now.
A 5.06% Medicare Advantage Rate Increase for 2026: What It Means for Practices
CMS finalized a 5.06% average payment increase for Medicare Advantage plans in 2026 on April 7, 2025, well above the January estimate. Here is what drove the number, what the completed V28 risk model phase-in means for coding, and what practices with MA contracts should do before plans file bids in June.
UnitedHealthcare's February 1 Edits and Other Early-2025 Payer Changes
UnitedHealthcare's January 2025 bulletin brought new shoulder arthroscopy edits, radiation therapy unit limits and a code retirement for April 1. Here is what changed, who it affects, and the monthly routine we use to keep payer policy changes from turning into denials.
UnitedHealthcare's Gold Card Started October 1: Who Qualifies and What Changes
UnitedHealthcare launched a national Gold Card program on October 1, 2024 that waives prior authorization for qualifying groups on selected codes. Here is how eligibility works at the TIN level, why "no prior auth" still means an advance notification, and how to check and protect your status.
UnitedHealthcare's Gold Card Program: Tracking Prior Authorizations to Qualify
UnitedHealthcare announced a national Gold Card program on August 1, effective October 1, 2024, that exempts qualifying groups from prior authorization on selected codes. Qualifying depends on a two-year approval rate the payer calculates. What it requires, how the math works, and the tracking that gets you there.
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