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Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
Payers Must Post Prior Authorization Metrics by March 31, 2026: How to Read Them
Under CMS-0057-F, Medicare Advantage, Medicaid managed care, CHIP and exchange plans must publish their 2025 prior authorization approval, denial, appeal and turnaround numbers by March 31, 2026. Here is where to find them, what they can and cannot tell you, and how to use them in appeals and contract talks.
The Marketplace 90-Day Grace Period: Why Claims Pend in Months Two and Three
Eligibility says active, the claim goes out, and nothing comes back for weeks. The patient is in the Marketplace 90-day grace period, and the plan may hold your claim until the premium is paid or coverage is cancelled retroactively. We explain the rule, why 2026 is a bad year for it, and how to protect the practice.
The HIPAA Security Rule Update Is Still Pending: What to Do While You Wait
HHS proposed the biggest rewrite of the HIPAA Security Rule in two decades in January 2025. As of March 2026 there is still no final rule. Here is what the proposal would require, why waiting for it is a mistake, and the seven steps a practice can take this spring that will be needed under any version.
RADV Audits for Payment Year 2020 Began in March 2026: Expect MA Chart Requests
On March 20, 2026 CMS told Medicare Advantage organizations which contracts are selected for payment year 2020 risk adjustment audits, the first wave under the program expanded in May 2025. Plans have five months to gather records, so requests for 2019 charts are coming. What to expect and how to respond.
PCMH Care Plans That Meet the Care Management Criteria: Elements and Cadence
A PCMH care plan is not a problem list with a date on it. NCQA's care management criteria ask for patient goals, barriers, a self-management plan and a written copy in the patient's hands, reviewed on a schedule. We lay out the elements, a worked example and a review cadence that keeps annual reporting painless.
Payer Audit Records Requests: Answering a TPE or SIU Letter for 20 Charts
A letter arrives asking for 20 medical records within 45 days. Whether it comes from a Medicare contractor running Targeted Probe and Educate or a commercial plan's special investigations unit, the next six weeks decide whether this ends in education or in recoupment. Here is how we handle payer audit records requests.
JW and JZ Modifiers: Drug Wastage Billing and the Drug Charges Practices Miss
Since October 2023 Medicare returns single-dose drug claims that lack a JW or JZ modifier, and most practices fix them one rejection at a time. The rules, the billing-unit arithmetic behind most drug underpayments, a worked infusion example and the three-report audit that finds missing drug revenue.
PCMH Version 11.1 Is Now the Standard: Evidence Habits for 2026 Annual Reporting
NCQA PCMH Standards and Guidelines version 11.1 took effect January 1, 2026, raising the medication reconciliation threshold to 90.1 percent and tightening care plan documentation. Recognized practices report against it this year. Here is what changed and the weekly habits that make the evidence easy.
NCCI Edits Explained: Modifier 59, the X Modifiers and Bundling Denials (CO-97)
Bundling denials are the most misunderstood line on the remit. How the National Correct Coding Initiative edits work, what the modifier indicator means, when modifier 59 or the XE, XS, XP and XU modifiers are legitimate, the office procedure pairs that trip the edits most, and how to correct without unbundling.
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