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Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
CY2026 Fee Schedule Final Rule: Two Conversion Factors and One Efficiency Cut
CMS released the CY2026 Physician Fee Schedule final rule on October 31, 2025. The conversion factor rises to $33.40, or $33.57 for advanced APM participants, but a 2.5 percent efficiency adjustment hits procedural codes and skin substitutes move to a flat per-square-centimeter rate. Here is what changes on January 1.
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.
Denial Prevention for High-Dollar Procedures: A Pre-Claim Review That Pays
A denied $28,000 implant claim costs more than a hundred denied office visits. Here is how to define high-dollar claims, the eleven-point check before they leave the practice, a worked example, and why this matters more with WISeR arriving in January 2026.
Prior Authorization Staffing Models for Independent Practices in 2025
The AMA's latest survey puts prior authorization at 39 requests per physician per week and about 13 hours of staff time. Here is how practices staff it, the volume math for each model, the metrics that tell you it is working, and what the summer 2025 payer commitments change.
CY 2026 OPPS Proposed Rule: Inpatient-Only List and Site-Neutral Payment
CMS released the CY 2026 OPPS and ASC proposed rule on July 15, 2025: a 2.4 percent update, a three-year phase-out of the inpatient-only list starting with 285 procedures, and site-neutral payment for drug administration in off-campus departments. Here is what it means outside the hospital.
A 90-Day Plan Before the October 1 ICD-10-CM Update (487 New Codes)
The FY 2026 ICD-10-CM update takes effect October 1, 2025 with 487 new codes, 38 revisions and 28 deletions. The practices that lose money on code updates are the ones that start in September. Here is a week-by-week plan starting now.
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.
CY 2026 Physician Fee Schedule Proposed Rule: What Practices Should Model Now
CMS released the CY 2026 Physician Fee Schedule proposed rule on July 14, 2025. Two conversion factors, a 2.5 percent efficiency adjustment, a practice expense cut for facility-based services and a skin substitute overhaul. Here is what to model and what to comment on.
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