Practical knowledge from people who do the work.
Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
After the Election: Five Health Policy Items Practices Are Watching Now
The November 5 election is over and the practical questions for practices are the ones that were pending before it: the December 31 telehealth expiration, the 2.83% Medicare cut, ACA subsidy timing, Medicare Advantage disruption during open enrollment, and cybersecurity rules. Here is what is decided and what is not.
CY2025 Physician Fee Schedule Final Rule: 2.83% Cut, APCM Codes and Telehealth
CMS published the CY2025 Physician Fee Schedule final rule on November 1, 2024. The conversion factor falls to $32.35, three Advanced Primary Care Management codes arrive, G2211 gains a modifier 25 exception, and Medicare declines to pay for 16 of the 17 new CPT telemedicine codes. Here is what changes on January 1.
Change Healthcare Breach Reaches 100 Million: What Practices Owe and Should Ask
Change Healthcare told federal regulators on October 22, 2024 that about 100 million breach notices have gone out, the largest healthcare breach ever reported. Here is where a practice's HIPAA obligations stand, what the notification delegation means, and the questions to put to every vendor that touches your claims.
How to Run a Fourth-Quarter Denial Review, Including the Timely Filing Check
A fourth-quarter denial review has one purpose: recover what can still be recovered in 2024 and stop the same denials from following you into January. Here is the report set, the buckets by cause, the timely filing audit that belongs in the same week, a worked example, and how to turn the findings into three fixes.
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.
How to Build a Denial Dashboard Your Practice Will Actually Use Every Week
Most practices have denial reports nobody reads. A denial dashboard is different: eight fields captured on every denial, six numbers reviewed weekly, and a category scheme that points at the process that failed. Here is how to build one in a spreadsheet, with a worked example, before you buy software.
Billing Medicare Annual Wellness Visits (G0438, G0439) Without the Usual Denials
The annual wellness visit is one of the few Medicare services with no patient cost sharing, and one of the most frequently denied. Here is how the IPPE, first AWV and subsequent AWV fit together, what documentation each requires, how to add a problem visit with modifier 25, and the denials to prevent.
MIPS 2024 Mid-Year Checkpoint: What to Review Before the Second Half of the Year
The 2024 MIPS performance year is half over, the threshold to avoid a penalty is 75 points, and the penalty for missing it is up to 9% of 2026 Medicare Part B payments. Here is the review to finish in July: eligibility, the 180-day Promoting Interoperability window, quality data and the mistakes that cost points.
Medicaid Unwinding Is Ending: How to Stop Losing Visits to Terminated Coverage
Most states have finished or nearly finished their first round of Medicaid renewals, and more than 20 million people have been disenrolled since April 2023, most of them for paperwork reasons. Here is how the losses show up in a practice's denials and the eligibility routine that stops them.
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