Ten Years of 2016 Lab Prices End on January 1
The Medicare clinical lab fee schedule has been priced off private payor rates collected in the first half of 2016, and hasn't moved a dollar since 2020. The reporting window that resets it closed Friday. Starting January 1, rates can fall 15% a year for three years, and the book of business underneath them looks nothing like it did in 2016.
The Diff
Every brief →- Aug 27 min read
How a Missing Sign Becomes an Overpayment
CMS wants every Medicare revocation ground to reach back to the day compliance broke, and it wants your last claims filed within 15 days of the letter. The enrollment half of the home health rule applies to every provider type, and comments close August 31.
Subscribers - Aug 26 min read
Half of CJR-X Savings Is a Check You Write
CMS made joint replacement bundles mandatory and national on Friday, starting January 1, 2028. The rule projects $736 million in Medicare savings across five years. Its own table shows participants repaying $1.855 billion and collecting $1.463 billion back, and the sensitivity analysis books savings even if nobody changes anything.
Subscribers - Aug 14 min read
Who Eats the Other 35% of an NTAP Case?
CMS approved 19 technologies for new technology add-on payments in the FY 2027 inpatient final rule, and priced each one. A single drug is $455 million of the $899 million. The add-on tops out at 65% of what that drug costs, which leaves $154,581 a case sitting inside the MS-DRG payment.
Subscribers - Aug 15 min read
The Downcode Record: What July Actually Cost
The record opens here. Four FY 2027 final rules added $2.04 billion to Medicare post-acute payment in the last week of July. The proposals still open take $5.5 billion out in year one, and the Medicaid provider tax rule another $246 billion over a decade. Every change the desk tracked in July, priced, with the date it starts.
Subscribers - Aug 14 min read
How PEPPER Got Rebuilt
The free CMS report that tells a facility where it sits against its peers on the metrics auditors use went dark in 2023. A small Maryland contractor has been putting it back one facility type at a time, and the last of them lands in September.
Free - Jul 314 min read
Why Your IDR Recovery Timeline Is Out of Date
The Departments released the second-half 2025 federal IDR public use files on July 22. The share of payment determinations landing inside 30 business days went from 29% to 62% in a year, the default wins that padded provider win rates are thinning, and the operations rule takes effect August 3.
Free - Jul 316 min read
The 11.6% Inside a 2.4% Outpatient Update
CMS summarized the CY 2027 outpatient proposed rule as a 2.4% update. The conversion factor moves from $91.415 to $102.004, because paying 340B drugs at ASP minus 33.4% pulls $4.85 billion out of drug payment and statute puts it back into everyone's non-drug rates. The agency's own impact model puts 13.4 points between for-profit and major teaching hospitals.
Subscribers - Jul 315 min read
CMS Spent the Week Adding Paperwork
Seven days on the CMS docket: 22 HCPCS codes pick up a face-to-face requirement, eight pick up prior authorization, and the FY2027 SNF and psych final rules landed. Every change, the codes it touches, and the dates that start the clock.
Subscribers - Jul 283 min read
How We Catch the Change Nobody Announced
The policy changes that cost the most rarely come with a press release. The Downcoded method, end to end: where changes surface, how the diff works, and how a diff becomes a dollar figure.
Free - Jul 243 min read
The Senate Wants the Algorithms
Blumenthal and Hawley gave UnitedHealthcare, Humana, and CVS until Monday to hand over their denial-algorithm inventories. We read the record already on the table, and what a revenue-cycle lead should do with it now.
Subscribers - Jul 214 min read
What Happens When Your Hospital Quits Medicare Advantage?
More than 20 health systems have dropped or narrowed MA contracts this year, and insurers pushed 2.9 million members off their plans. We trace what an exit market does to the revenue cycle on both sides of the divorce.
Subscribers - Jul 184 min read
The 56 Cents Coming Out of Every RVU
CMS proposes a $32.84 conversion factor for CY2027, down 1.68%. We price the cut by practice shape, read the specialty impact tables, and set the September 14 comment clock.
Subscribers - Jul 163 min read
Why We Price the Paper Trail
Downcoded machine-reads the documents payers already publish, diffs every one against its prior version, and models what each change costs by specialty. An introduction to the desk and the record it keeps.
Free
The payer changed the rules again.
We find every change in the record, price it by specialty, and put it in front of you before the effective date.