Why Does One California Episode Need Two Pre-Claim Reviews?
CMS rebuilt the Review Choice Demonstration operational guide on November 2 and put every California home health agency under review for billing periods beginning January 18. Two sentences in it apply to California alone: a pre-claim review request may carry only one 30-day period, and the multiple billing period option is off. The collection OMB approved says providers may bundle. Priced at CMS's own 30 minutes and $44.28, the carve-out is worth $14.8 million a year, and the revision's hour count did not move.
The Diff
Every brief →- Nov 37 min read
Your Patch Monitor Just Inherited an Event Recorder's Rules
CGS and Palmetto retired an eleven-year-old Cardiac Event Detection LCD on June 27 and replaced it with a policy whose own device table names Holter and both extended-wear patch tiers. The payable diagnosis list went from 60 codes to 238, the fourteen acute-MI codes called out as non-covered are gone, and the exclusive-use and overlapping-billing denials came across intact onto $229.6 million a year of patch volume.
Subscribers - Nov 35 min read
The $16.5 Million Medicare Spent to Say No
CMS published a 55-page final rule this morning rewriting how organ procurement organizations are designated, competed and de-certified, and used it to tell 54 of them that the performance cycle which just closed is final. The rule costs $16.5 million in year one against $598,000 in annual benefits by CMS's own count. Also in the window: the fee schedule's statutory deadline passed on Sunday with all three rate books still inside OMB, and the psych unit attestation that decides your payment system is up for reinstatement.
Subscribers - Nov 34 min read
Lafayette, Louisiana Is the Capital of Medicare's Dementia Model
CMS refreshed its Innovation Center participant roster on November 2. The GUIDE dementia model now carries 286 rows across 45 states, and the state with the most of them is Louisiana, ahead of California and Florida. Twenty-eight of Louisiana's thirty-three are Curana Health, filed one legal entity per state from a single Lafayette address, and the July fact-sheet revision added two dementia codes that exist only for the kind of patient Curana sees.
Free - Nov 23 min read
Who Checked the Private Equity Box?
CMS has asked institutional providers to name their private equity and REIT owners since January 2024. We pulled all four hospital and nursing home ownership files it rebuilt on October 19: the private equity box is checked on 0.68 percent of nursing home enrollments, and the file that records the actual sale does not carry the field at all. The CY2027 home health rule proposes to put the same question on your 855B.
Free - Nov 26 min read
Three Jurisdictions Sat Out the New Nerve Block Policy
Five Medicare contractors now run one rewritten chronic pain nerve injection policy across nine of the twelve A/B MAC jurisdictions, and the longest of the predecessor covered-code lists drops from 31 codes to 14. Novitas and First Coast never adopted it, and $40.0 million of the dropped codes sits in their jurisdictions.
Subscribers - Nov 23 min read
How Electrostimulation Left the Policy That Named It
Palmetto's retired peripheral neuropathy LCD had the word electrostimulation in its title. The policy that replaced it on October 25 does not mention G0283 anywhere, and G0283 is a 5.4 million service code. We priced it: $47.7 million a year, and the only two contractors that ever wrote a policy for it both retired that policy on the same morning.
Subscribers - Nov 14 min read
The Penalty Pool Is Now a Nurse Recruiting Budget
CMS launched Nurses for Nursing Homes on October 23 with $275 million in civil money penalty collections and no appropriation, then published the thing federal programs almost never publish: the selection function that decides which buildings qualify. We ran it. 9,181 of the country's 14,686 certified nursing homes are on the list, and the stipend picked up a wage index adjustment somewhere between launch day and this morning.
Free - Nov 17 min read
The Downcode Record: Three Rate Books and Thirty-One Days
Three of the four CY 2027 Medicare rate books are still inside OMB this morning, and without a waiver finding the last date one can publish and still bite on January 1 is December 2. The one that got out, dialysis, took 41 days and came in $2.03 under its own proposal. Home health hits 41 days today.
Subscribers - Nov 15 min read
The $62 Million UnitedHealthcare Took Off Clinical Review Today
UnitedHealthcare retired two medical policies effective today, across commercial, Individual Exchange and Community Plan at once, with the same sentence attached to each: the service no longer requires clinical review. Priced against the 2024 Medicare file, one of them is $1.8 million a year and the other is $62.6 million.
Subscribers - Oct 314 min read
What Happens When Half Your DRG Adjustment Is a Proxy?
Two factors multiply every base operating DRG payment this fiscal year. CMS published the readmission one on October 7, down to the ten hospitals sitting on the 3 percent floor. The value-based purchasing half is still the proxy table from July, the one CMS labelled as not for payment, and the agency's own proxy for readmissions missed the final factor by an average of 25.9 basis points.
Subscribers - Oct 317 min read
The 2,900 California Agencies Medicare Forgot to Count
CMS asked OMB on Friday for emergency clearance to put California home health under the Review Choice Demonstration, citing significant fraud. California billed $3.26 billion in CY2024, seventy percent of the six states already in the program, and the burden estimate attached to the request does not move by a single hour. That is because the hour count was never a count of anything: CMS built it by multiplying a postage bill by half an hour, and the notice carries the same number to a seventh state.
Subscribers - Oct 314 min read
How Your JW Modifier Becomes a Manufacturer's Invoice
Medicare billed drug manufacturers $173 million for discarded Part B drug, and the arithmetic runs entirely off JW units sitting on provider claims. Payment on the newest report is due December 31.
Free - Oct 305 min read
Half of Medicare's Mismatched Drug Codes Are Saline
OIG spent fourteen months inside one year of Part B drug claims and came back with 160,918 lines where the HCPCS code does not match the NDC sitting beside it. Three saline codes are half of them, nothing in the claims system edits for it, and the brief closes with no recommendations. Also in the window: the fee schedule's statutory deadline runs out today with the OMB tracker returning 502 on every path, and Cigna quietly moved its entire coverage policy library to a new domain.
Subscribers - Oct 304 min read
Amazon and Google Want the Prior Auth Pledge in Their Own Plans
CMS and the Labor Department announced on October 21 that five large employers signed a statement asking their third-party administrators to extend the 2025 Prior Authorization Pledge to self-funded plans. The January 1, 2027 API mandate reaches five categories of payer, and an ERISA plan is not one of them, which matters because 71 percent of covered workers now sit in one.
Free - Oct 296 min read
Who Bills the Ambulance Claim Your Trauma Payment Now Needs?
On January 1 Aetna starts denying trauma response revenue codes 0681 through 0684 unless a paid G0390 and a paid qualifying ambulance transport charge both sit on the same date of service. Medicare's own rule asks for two things and neither of them is an ambulance claim. The line at risk is the $1,361.78 activation add-on, and the condition that decides it lives on a claim filed by a different NPI.
Subscribers - Oct 295 min read
The Twenty-Eight Questions Behind Your Next Fraud Investigation
CMS has a draft contract out for the entity that investigates providers, and it moves lead generation and final sign-off to CMS itself. Responses close November 4, and the manual that governs the current model is the one CMS told respondents to ignore.
Subscribers - Oct 294 min read
Nobody Published Fiscal 2024's Fraud Enforcement Numbers
OIG's Health Care Fraud and Abuse Control report has one entry per fiscal year, unbroken, from 2005 to 2023. Then it skips to 2025, and the 2025 edition that posted Wednesday is a single page. The eight numbers that fit on it include 2,837 new exclusions, the most since 2017, and 861 civil actions, the most in a decade.
Free - Oct 285 min read
Why the Dialysis Rule Left OMB Before the Fee Schedule
One of the four CY2027 Medicare rate books has dropped off OMB's pending review list, and it is the only one of the four whose statute names no publication date. The physician fee schedule, which does, is still inside on day 29 with two business days to beat it. Also in the window: Aetna's November bulletin surfaced after five weeks of 404s and puts eleven things on the precertification list while taking none off, two of them effective Sunday.
Subscribers - Oct 284 min read
The One Negative Row in Medicare's New Dialysis Rate Book
CMS filed the CY2027 ESRD final rule at 4:15 this afternoon, nine hours after we flagged that it had cleared OMB with nothing yet at the far end. The agency scores it as a 2.7 percent raise worth $240 million. Its own impact table has thirty rows, exactly one of them is negative, and the base rate's $15.81 increase is mostly drug money changing buckets.
Subscribers - Oct 284 min read
Pennsylvania Published Ten Carriers' Prior Auth Denials
The federal transparency file has 6,764 plan rows and not one of them is from Pennsylvania. The state's insurance department fills the hole itself, and its fourth edition, posted yesterday, is the first to carry the new pre-service table: 1,569 prior auth appeals, 379 overturned, and an external reviewer that sided with the member about half the time.
Free - Oct 276 min read
What Happens to a Payment Suspension After Eighteen Months?
CMS issued Transmittal 14002 on Monday with a summary insisting it does not affect providers and needs no provider education. It revises one section of the Program Integrity Manual, and the red italics tell the fraud contractors to stop sending resolution letters once a case or payment suspension is three years old. The suspension regulation says good cause to end one must be deemed to exist at eighteen months. Here is the diff, that clock priced per $100,000 of monthly Medicare cash, and the enforcement volume that built the backlog behind it.
Subscribers - Oct 277 min read
The Five Criteria MIPS Will Still Require After They Stop Existing
ONC's HTI-5 final rule deletes 14 certification criteria, seven of them on January 1. Five of those seven are named by cite in the MIPS CEHRT definition at 42 CFR 414.1305, which has no sunset in it. Hospitals got their conforming fix in August. The clinician version is sitting in a final rule that has not published.
Subscribers - Oct 274 min read
Every Part D Plan Wants a Prior Auth on Negotiated Semaglutide
The first CMS formulary file carrying contract year 2027 landed on October 15, and it is the first look at how Part D plans will handle the fifteen drugs whose negotiated price starts January 1. Semaglutide goes from presentations listed on as few as 16 of 328 formularies to all 286, and all 5,495 plans put a prior authorization in front of every strength of it.
Free - Oct 264 min read
Thirteen Comorbidities That Lower Your Mortality Index
AHRQ's Elixhauser comorbidity software prices 38 conditions into a risk-of-death score, and thirteen of them carry a minus sign. The crosswalk is 4,567 ICD-10-CM codes, the coefficients are printed in a free PDF, and ten of the thirteen flip positive the moment you switch to the readmission index. Until September the whole thing ran only in SAS.
Free - Oct 265 min read
Medicare Has Made Its Own Rate Book Deadline Once in Eight Years
Four CY2027 rate books sit at OMB this morning, all four flagged with a statutory deadline, none of them on public inspection. The statute behind the physician fee schedule says before November 1, which leaves five business days counting today. We pulled the filing instant off eight years of Federal Register public inspection copies: CMS has cleared that line once, at 5:10pm on a Friday with under seven hours to spare. Also in the window: a coverage database that is eight days behind its own data, and four MAC pain policies that went live inside the gap.
Subscribers - Oct 264 min read
How One Asterisk Decides Who Bills a Nursing Home Debridement
CMS has printed the same asterisk legend on its SNF therapy bundling file every year since 2020 and marked nothing with it. The CY 2026 file marks 49 of 107 codes, the marks say bundling now turns on who furnished the service, and the CWF edit that enforces the list only knows codes.
Subscribers - Oct 256 min read
Your Brace Price Now Belongs to Three Bidders
CMS published the Round 2028 contract counts in August and set the bid clock on October 7. Registration opens December 1. The counts are 125 percent of a supplier count CMS never published, and running the arithmetic backwards says Medicare found exactly two suppliers that matter in off-the-shelf back braces, a code that moved $78.6 million last year. The 2024 public use file says the same thing. If your practice hands a brace to its own patient, you are paid the price those bidders set and you are not allowed to bid.
Subscribers - Oct 256 min read
Who Got to Comment on Your Morton's Neuroma Coverage?
Noridian revised its tendon, ligament and ganglion cyst LCD on September 29 with one sentence of explanation and no list of what changed. Four CPT codes and nine diagnoses come off on November 1, worth $2,021,923 of CY2024 allowed in its own 15 states. 64632 lands on an explicit non-covered list where one diagnostic injection is permitted, and 68 percent of its dollars sit above the first. The comment window that decided all of it closed on November 8, 2025, on a document with a different name and a different number.
Subscribers - Oct 253 min read
How to Read an OIG Audit That Has No Title
Sixty-six active HHS-OIG audits of Medicare carry no title at all, only their own project number. The narrative, the series and the already-published siblings tell you what each one is checking, and the biggest block of them is pointed at Part C diagnosis codes.
Free - Oct 245 min read
Who Pays for HIPAA's $3.2 Billion in Savings?
An economically significant HIPAA Privacy Rule final rule has been sitting at OMB since April 2. It is day 205, longer than all four CY2027 rate books put together, and the Unified Agenda's own target was August. The proposal underneath it cuts your records response from 30 days to 15, bans a fee on anything a patient pulls through the portal, and makes you post a price list. The impact analysis books $4.4 billion of savings and not one dollar of it against any of that. Also in the window: a 203-page Exchange verification rule filed Friday afternoon, and 155 lab codes where CMS did not agree with its own advisory panel.
Subscribers - Oct 244 min read
The Panel Voted Gapfill 160 Times and Won 22
Four hundred eleven lab codes went through Medicare's 2026 reporting window without a single private payor rate reported. The expert panel the statute tells CMS to consult voted to gapfill 160 of them, CMS substituted a crosswalk on 138, and $140,591 of rate value is riding on a comment window that closes November 19.
Subscribers - Oct 244 min read
Medicare Pays More to Read the Scan Than to Take It
Four Category III codes for automated coronary plaque analysis carried zero RVUs last year, because contractors priced them one claim at a time. On January 1 they became a single Category I code, 75577, worth 30.30 RVUs and $1,012.05, more than three times the CCTA it runs on. Five of the eight contractors that write local coverage already cover it, four of them from the same day, and not one of the five wrote the policy on its own initiative.
Free - Oct 234 min read
Two Years for a Standards Case, Ten for an Affiliation
Medicare's re-enrollment bar is a severity grade CMS writes in years, and it publishes the grades without ever calling them that. We diffed the revoked-provider extract CMS posted October 21 against the July build: 940 enrollments arrived, 456 left, and the two populations are nothing alike.
Free - Oct 236 min read
Seven Osteomyelitis Codes Didn't Make Medicare's Oxygen List
CMS issued the April 2027 NCD coding update this morning, three weeks after the codes inside it took effect. Four coverage policies wait until April 5 for edits dated October 1, the hyperbaric oxygen list comes back seven codes short and stays that way, and the spreadsheet that would show you the rest is a dead link.
Subscribers - Oct 236 min read
How 57 Hospitals Get the Full Market Basket
CMS set the CY2027 rural emergency hospital facility payment on Thursday at $304,492.86 a month after sequestration. The 3.2 percent raise behind that number is the hospital market basket with nothing taken out of it, 0.9 points more than every IPPS hospital got for the same year, and four years of that difference is worth $158,136 a hospital.
Subscribers - Oct 224 min read
Your A/R Days Are the One Thing That Held Still
We ran days in A/R and days of cash on the same 3,598 hospital balance sheets for five straight fiscal years, straight out of Medicare's own cost report files. The revenue-cycle number moved a fifth of a day. The cash number lost 17.7. And the receivable sitting above the national median adds up to $70 billion.
Subscribers - Oct 225 min read
What Does One Word Do to a Repeat Facet Ablation?
Novitas and First Coast posted their facet joint policies for notice this morning, effective December 6. The whole revision is one conjunction: 'and' becomes 'or' in the repeat radiofrequency ablation criterion. The other five MACs already carry it, and Palmetto logged the edit last October. The two jurisdictions arriving last hold $117.1 million of Medicare's facet ablation money, 39.7% of the national total. Also in the window: CMS quietly suspended the four-day IRF clock it set three weeks ago, and a gene therapy that has to be billed as thirty claims.
Subscribers - Oct 224 min read
Three Rivers Health Put Its Turnaround on Worksheet G
A 10-bed critical access hospital in Basin, Wyoming says it pulled $2.6 million out of an aged claims backlog and went from six days of cash to 111. Every one of those numbers also sits in its filed Medicare cost reports, which means the same check runs on anybody.
Free - Oct 217 min read
The 298,527 Claims Medicare Paid Twice
CMS published a new computer matching program with the Veterans Health Administration this morning, and it is the first CMS/VA match that moves claim lines rather than enrollment records. The file VHA gets back carries billing NPI, procedure codes, dates of service and payment amounts on every claim both agencies paid. It can start running November 20.
Subscribers - Oct 213 min read
Medicare's Busiest Enrollment Month Is Also Its Fastest
CMS publishes the stock of unprocessed initial enrollment applications twice a week and never the flow. We diffed all 352 archived builds of both files into arrivals and departures. The physician list takes 69 percent of its year in four months, and those are the four months where the fewest applications fall behind.
Free - Oct 216 min read
How a Hospice Election Date Becomes an Automated Denial
CMS approved two Recovery Audit topics on September 24 and posted four more to the proposed list yesterday. Three of the six run the same rule, that services related to a terminal diagnosis during a hospice election belong to the hospice, against physicians, ambulance suppliers and home health agencies. All three are automated reviews, so no record gets read, and the most expensive claim unit in the set is a 30-day home health period at $2,038.22.
Subscribers - Oct 204 min read
Which Arbitrator Did Your IDR Dispute Draw?
The federal IDR public use files started naming the certified IDR entity behind every determination this summer. Run the Q4 2025 file and the provider win rate goes from 98.2% at one entity to 56.1% at another, and it holds on a single ED visit code across two quarters. The entity-selection form moves into the IDR Gateway on November 13.
Subscribers - Oct 205 min read
Which 52,577 Medicare Enrollments Disappeared Last Quarter?
Medicare catalogued its quarterly provider enrollment drop on Monday. Net growth of 51,097 records hides 52,577 enrollment IDs that left the file, a DME supplier count going the wrong way, and hospice shrinking in two files at once.
Subscribers - Oct 204 min read
How a Patch Gets Into a Code Written for a Vest
CMS posted the agenda for its November 2 HCPCS meeting with 63 preliminary determinations on it, and two of them belong to Element Science. The ask was to strike the words 'garment type' from K0606 so a patch-based wearable defibrillator fits the code. CMS's preliminary answer is yes, plus a descriptor change nobody requested, and written comments close November 4.
Free - Oct 194 min read
Your Draft LCD Backlog Is Smaller Than the Database Says
The Medicare Coverage Database shows 93 proposed LCDs sitting past their comment close date, a median 345 days each. One column in the download export says 68 of them were released as final policy already, which puts the real queue at 25 drafts and 93 days. Twelve of the finished ones drop off the report between now and October 30.
Free - Oct 196 min read
The 25 Codes That Leave Noridian's Nerve Block List on Sunday
Noridian's chronic pain nerve block policy retires October 31 and its replacement takes effect November 1 with 14 covered codes where the old one had 31. The 25 codes that come off drew $18.3 million of Medicare allowed in Noridian's own states in CY2024, and five of them carry four fifths of it.
Subscribers - Oct 197 min read
Medicare's New PBM Rule Has No Row in Its Own Cost Table
CMS filed a 265-page proposed rule on Friday that spends 102 pages rewriting how pharmacy benefit managers get paid in Part D from 2028, then books no dollars and no paperwork hours against any of it. The ten-year impact table has two rows for three provisions, the burden table has 46,291 hours all sitting on Medicare Advantage directories, and that is how a rule creating twelve new sections of part 423 gets declared de minimis at $6 million.
Subscribers - Oct 183 min read
The Four States Medicare Picked First
Eight HCPCS codes join Medicare's Required Prior Authorization List on October 28, taking it from 74 codes to 82. Six land nationwide. The two that carry $71.4 million, L3761 and L3916, roll out in three state phases that reach a quarter of the money this month and half of it by January.
Subscribers - Oct 185 min read
Only One of Medicare's Enrollment Queues Is Getting Shorter
CMS rebuilt its enrollment files Friday morning, ninety minutes after this letter went out. Physicians waiting on an initial application fell to 4,582, down for ten straight builds and off 45.6 percent from July. Non-physician practitioners went the other way to 7,676, a 23-month high, and the same two regulations govern both. Also in the window: 324 providers lost ordering authority in that build, and the 265-page Medicare Advantage and Part D rule CMS filed Friday afternoon gets a publication date of Tuesday.
Subscribers - Oct 184 min read
How Centene Picks the TINs That Get a Gold Card
Centene opens a national gold card program in November to more than 160,000 providers, and it grades eligibility at the ordering and referring tax ID level, using historical utilization management data. Prenotification replaces the authorization, routing through Availity or Evolent depending on the service, and 70.9% of the members the card can reach sit in state-regulated Medicaid.
Free - Oct 174 min read
What Does a $1.60 Copay Cost Medicare?
CMS filed the rule that takes the low-income subsidy generic copay to zero in 2028 and priced it at $1.337 billion over ten years, for roughly 6 million enrollees. That is 65 times the compliance bill in the same document, and the rule's third section carries no CMS estimate at all. Comments close December 15.
Free - Oct 177 min read
The Ten-Year Records Clause Coming to Every MA Contract
CMS filed a 265-page Medicare Advantage proposed rule at 4:15 Friday afternoon. Buried in it is the directory audit the agency ran three times and never published: 44.29 percent of listings wrong. The fix adds two terms to every MA provider contract, one of which outlives the contract by a decade.
Subscribers - Oct 175 min read
Six Codes Came Off Cigna's Prior Authorization List This Year
Cigna put 37 more codes under prior authorization on October 1 and published the notice on October 16, two weeks after the requirement went live and without naming a single code. Across twenty-two monthly editions the desk pulled this run, Cigna has added 214 codes to its precertification list in 2026 and taken six off. In 2025 it took off 233.
Subscribers - Oct 164 min read
What Happens to 2.9 Million Medicare Advantage Members in January?
CMS posted the 2027 plan crosswalk on October 5, ten days before annual enrollment opened. It maps 943 Medicare Advantage plans to nothing: 2,943,980 members as of this month, 8.13 percent of the book, the fourth straight annual increase and the largest yet. 46 percent of Minnesota's Medicare Advantage enrollment sits in a plan that will not be offered, and $45.35 billion of 2027 benchmark payment is attached to plans that stop existing on December 31.
Subscribers - Oct 163 min read
Iowa Committed All $209 Million of Its Rural Award
CMS has spent the last 58 days publishing what the $50 billion rural program is actually buying, one state at a time: 38 press releases, 30 states, $2.42 billion named. Iowa is the only state CMS says has committed its entire first-year award. The newest release put $78 million directly on the books of 216 rural Texas providers.
Free - Oct 165 min read
How a Date on a Demand Letter Prices Your Appeal
Treasury's certified rate for Medicare overpayments holds at 11.875 percent on October 21, the first quarter in six that it hasn't moved and the highest of the six. The rate is fixed by the date your determination is written, not the date you pay, and it accrues straight through the appeal. Also in the window: CMS pushed its own terminated-provider collections cascade back 56 days, a MolDX coverage family retired and was replaced overnight, and a Federal Register notice published this morning carries the wrong collection title.
Subscribers - Oct 155 min read
Your IDT Meeting Now Needs Its Own Chart Entry
CMS revised four sections of the IRF benefit policy manual on Thursday, stamped them effective October 1, and gave the MACs until November 17 to implement. Two of the instructions that landed are not in the regulation at all: the day of admission is day 1, and the initial team meeting has to be documented separately from the plan of care.
Subscribers - Oct 154 min read
The One Year of Nursing Facility Visits Medicare Is Re-Reading
CMS republished the same optometry compliance notice on October 15 that it ran on July 16, word for word, on an OIG report it told the inspector general it would answer with education instead of claim reviews and system edits. Noridian is reviewing 99309 and 99310 anyway, dates of service 2023 only. CMS's own utilization file shows why 2023 is the year worth reading.
Free - Oct 156 min read
The 33,455 Exclusions That Start With a License Board
HHS delegated section 1128(b) of the Social Security Act to the CMS Administrator on Wednesday, effective immediately. The sentence it revised had said those authorities shall be exercised by the Office of Inspector General. 40,153 of the 84,093 names on the active exclusion list rest on that subsection, 33,455 of them on a state license action alone, and 91.65 percent of them carry no NPI for your screen to match.
Subscribers - Oct 134 min read
Medicare Has Been Gold Carding Since 2020
The hospital outpatient prior authorization program has carried an exemption since the day it opened. Ten requests, a 90 percent affirmation rate on initial submissions, and the MAC stops asking, permanently, with nothing to apply for. 257 outpatient departments held it in FY2024, your MAC is calculating the next cycle's rate this month, and the opt-out closes November 30.
Free - Oct 135 min read
How Late Can Your 2027 Rate Book Legally Be?
Four CY 2027 payment final rules are still at OMB and CMS has not published a document since October 9. The statute everyone quotes at 60 days sets the comment period, not the effective date; the provision that governs the gap is 30 days, which makes December 2 the last date a rate book can publish and still bite on January 1. Last year CMS published the home health rule on exactly that date. Also in the window: three October 8 transmittals nobody has worked, a DMEPOS document clock that opened a week ago, and a commercial side quieter than CMS.
Subscribers - Oct 134 min read
How a Lab Test Loses Its Price in Three Business Days
Medicare's advisory panel voted a specific crosswalk price for 110 new lab codes on September 15 and 16. CMS posted its own preliminary determinations the following Monday, replacing the panel's price with gapfill on 20 of them, including $95,508 of recommended payment across eight codes the panel valued above $7,500 each. The comment window closes this month and CMS has not published the date.
Subscribers - Oct 123 min read
What Happens to a Drug That Never Gets Its Own Code?
CMS posted its third-quarter 2026 drug coding summary on October 2 with 25 applications in it. Across 2026's three cycles the count is 67, against 118 in the same three cycles of 2025, the thinnest stretch in the nineteen summaries CMS still publishes. The products that never get a code keep getting billed, at 95 percent of average wholesale price, priced by hand.
Free - Oct 127 min read
The Twenty-Antibody Cap That Lasted Twenty-Four Days
On September 25 UnitedHealthcare raised its new specific IgE testing limit from 20 allergen specific antibodies a year to 29, and backdated the increase to September 1, the same date the 20 took effect. The 20 was the published number for twenty-four days of dates of service. Four lines of business got four different clocks, the Medicaid policy exempts seven of the twelve states its own bulletin announces it for, and nobody has said what happens to the September denials.
Subscribers - Oct 127 min read
Medicare Has Been Fixing This Home Health Edit Since 2023
CMS issued a change request Thursday that stops home health claims from being returned when the Notice of Admission has aged out of the system. The same three-line substitution was written in August 2021 and rewritten in July 2024, and this version does not touch a claim until April 5, 2027. Until then the fix is a person at your MAC building a replacement NOA every week, and the date that NOA carries is the date the Pricer prices against.
Subscribers - Oct 114 min read
Your Remit Can Now Offer You a Peer-to-Peer
CMS refreshed the free software that reads your 835 on October 5, and the code list behind it had picked up 18 new remark codes on July 1. Nine are dental imaging. One tells you a claim is already being reprocessed and to stop resubmitting it, and one tells you a peer-to-peer is available. The claim adjustment reason code list, meanwhile, has not moved since November 2025.
Free - Oct 114 min read
Why Modifier 25 Stops Being Free
The CY2027 physician fee schedule final rule has been sitting at OMB since September 29. Inside it is a proposal to pay the cheaper of a same-day office visit and global procedure at half rate, and $5.62 billion of last year's office-visit allowed charges rides on the lines it would touch.
Subscribers - Oct 115 min read
The Pharmacy List That Cleared OMB Before Your Rate Book
OMB concluded its review of CMS's draft program instructions for identifying essential retail pharmacies on October 8, seventeen days after they arrived, and cleared them Consistent with Change. The four CY 2027 payment rules that set your rates are still in the queue at 24, 24, 20 and 12 days. The statute behind the pharmacy file carries a plan year 2027 reporting date, 82 days out. Also in the window: a surveyor worksheet that now collects the CCN of every provider you are affiliated with, and two more rural transformation packages.
Subscribers - Oct 104 min read
Where Five Stars Hits the Ceiling
CMS put the 2027 Star Ratings on Plan Finder Thursday and open enrollment runs October 15 to December 7. We counted the places where a star rating cannot move the benchmark at all: in 950 of the 3,248 rows in the 2027 rate book the 5 percent and 3.5 percent bonus columns print the same number, and in 422 of those the 0 percent column matches too. A year earlier the count was 809.
Free - Oct 107 min read
UnitedHealthcare Is Waiting on a Rule CMS Never Proposed
The October commercial bulletin gives OB practices two branches for January 1: use CMS's maternity G-codes if they are finalized as proposed, otherwise switch to phase-based reporting. CMS never proposed the G-codes. It asked a question about them, the comment window closed 26 days ago, and the branch UnitedHealthcare files under 'if not' is the only one on the table.
Subscribers - Oct 106 min read
The $50 a Day Your Hospice Admission Date Decides
CMS issued CR 14622 on Thursday and logged a provider education revision yesterday that has not published. The change request reschedules the long-stay hospice edits CMS quietly switched off on June 18 after they started rejecting legitimate transfer claims. They come back April 5, 2027, and the one field they police is worth $50.00 a day past day 60.
Subscribers - Oct 94 min read
Which of Your Plans Just Fell Out of the Four-Star Club?
CMS posted the 2027 Star Ratings data tables on Thursday, and they set 2028 quality bonus payments. We diffed every Medicare Advantage contract against its restated 2026 rating: 72 contracts carrying 4.9 million members dropped below the 4.0 line and 35 carrying 4.8 million crossed it going the other way. Twelve of the fallers are UnitedHealth's and twelve of the climbers are Humana's, and the rate book prices the swing at $665.91 a member a year.
Subscribers - Oct 94 min read
The IDR Gateway Wants Your Open Disputes Claimed by November
CMS opened account creation for the IDR Gateway on September 15 and shipped the file-validation rules the same month: one CSV, 50,000 records, confirm or deny ownership of every open dispute your organization started before the new system existed. Confirmed disputes become processable in the Gateway by mid-November, and the legacy web forms stop working outside it after January 15.
Free - Oct 95 min read
How a Bounced Email Turns Off Your Eligibility Checks
CMS said on Thursday that a HETS EDI enrollment whose email fails to deliver three months running gets suspended, and every eligibility request submitted for that NPI gets rejected. The first of the three sends went out October 1, seven days before anyone was told, and your clearinghouse is not allowed to fix it. Also in the window: nine transmittals in one day, an ASC update implemented three days before it issued, and 41 fewer four-star Medicare Advantage contracts.
Subscribers - Oct 86 min read
What April 2027 Does to Your 2023 Nursing Home Claims
CMS issued a change request this morning that writes a one-time utility across 601 days of paid Part B history, flagging every line billed with place of service 32 that overlaps a Part A skilled nursing stay, and tells the MACs to reprocess them under standard recoupment procedures. The dates of service start May 11, 2023. Your nursing facility visit codes are the one thing it cannot take back.
Subscribers - Oct 86 min read
The Lab Director Rule CMS Never Made You Follow
CMS and the CDC proposed a 51-page CLIA rewrite this morning that undoes most of what the 2023 personnel rule did to laboratory directors. The qualification it unwinds has been law for 649 days, was enforced for 177 of them, and the relief that followed went to state surveyors rather than to the practices holding the certificate. For dermatology, where a fifth of all Certificate of Compliance labs sit, the median Mohs surgeon bills $215,230 a year through the certificate in question.
Subscribers - Oct 84 min read
Medicare Just Added $1.9 Billion to Its 2011 Charity Care
On September 24 CMS quietly wrote a fresh copy of its 2011 hospital cost report file, the one whose name ends in Final. We pulled the copy it served before and diffed the two. The national cost of charity care for fiscal 2011 went up $1.86 billion, 2,001 of 6,150 reports came back with a new primary key, and total costs and net income barely moved at all.
Free - Oct 74 min read
Who Did Medicare Leave Off Its Four-Million-NPI List?
CMS surfaced the fourteenth edition of its missing-digital-contact-information file today: 4,034,057 individual NPIs, up 81,839 in a quarter, and the list has never once gotten shorter. Behind those names sits $81.5 billion of CY2024 Medicare payments, 82.9% of every dollar Medicare paid an individual clinician. The file also leaves off 97.2% of pathologists, and on a sample of thirty of them, twenty-five have no digital address either.
Subscribers - Oct 75 min read
Three of Your 2027 Rate Books Are Running Early
All four CY 2027 Medicare payment final rules are sitting at the Office of Management and Budget right now, and three of them got there weeks earlier than last year's did. Home health arrived 33 days ahead of its CY 2026 pace. Run last cycle's transit times forward and the outpatient rate book publishes in the first week of November instead of Thanksgiving week. Also this week: one new rule in the queue, and the paperwork that counts Medicaid disenrollments.
Subscribers - Oct 74 min read
The 154,137 Codes Behind a Ninety-Second DRG
AKASA took the inpatient mid-cycle autonomous on October 2, the one stretch of the revenue cycle that still ran on a person reading the chart. The code set it picks from had turned over the day before, to 154,137 live entries and a new grouper.
Free - Oct 67 min read
The Case-Mix System Medicare Told Reviewers to Keep Using
CMS rewrote the home health chapter of the Program Integrity Manual on September 30, six and a half years after the CARES Act let nurse practitioners and PAs certify. The same transmittal quietly swapped HHRG for PDGM in the coding instruction, a line that had been pointing at a retired payment system since January 1, 2020. The summary of changes does not mention it, the one business requirement goes to a single contractor type, and provider education is listed as none. Effective November 2.
Subscribers - Oct 63 min read
Medicare Reposted the Roster It Called Final
CMS replaced the CY2027 Ambulatory Specialty Model participant list on October 3 and said so nowhere. The roster did not move: same 5,533 clinicians, same 232 markets, same $1.3 billion of CY2024 Medicare billing behind the plus-or-minus 9 percent the model puts on them. Exactly one column changed, and it was the one that costs nobody a dollar.
Free - Oct 66 min read
How a Payer Deletes You From Its Price File
Treasury, Labor and HHS finalized the Transparency in Coverage rewrite this morning. From March 6, 2027 every plan has to strip out the provider-rate pairs its own claims engine would deny and sign a chief executive's name to what is left, and the file that lets anyone check the deletions does not post until July 2028.
Subscribers - Oct 54 min read
Who CMS Hired to Make the Provider Record True
CMS signed a $77.6 million contract on September 24 for the ground truth under its National Provider Directory, and the winner was H1, a New York small business with no prior federal prime award and three provider-data acquisitions in twenty months. Five days later the directory reloaded: 14.2 million rows gone, every surviving row flagged active, and a Medicare Advantage plan-and-network layer that was not there in August.
Free - Oct 55 min read
The Wound Camera Seven MACs Proposed to Stop Paying For
Sixteen proposed local coverage determinations reached the Medicare Coverage Database on October 1 and fourteen of them propose non-coverage. All seven A/B MAC organizations filed the same draft against real-time fluorescence wound imaging, four more filed the near-infrared non-coverage policy Palmetto has run since 2023, and not one of the sixteen names a single HCPCS code. Comments close November 14.
Subscribers - Oct 54 min read
Medicare's Unpaid List Runs 208,661 Rows and Closes October 13
CMS published a correction this morning whose entire content is a hyperlink it forgot to print in August. The address leads to a spreadsheet naming 192,556 clinicians Medicare owes an APM incentive payment and cannot pay, and the claim deadline is eight days out. We matched the list against CMS's own CY2024 payment file: the money on the table models to between $187 million and $239 million, and oncology holds twelve percent of it on two percent of the names.
Subscribers - Oct 47 min read
Who Pays First When OPM and CMS Disagree?
CMS issued Change Request 14603 on Friday to end a four-year standoff with the Office of Personnel Management. For a federal retiree drawing workers' compensation, Medicare pays first and the FEHB plan pays second, starting November 2. OPM's own public guidance still says the opposite, the change request tasks no claims system and orders no provider education, and the definition it leans on is cited to a part of the Code of Federal Regulations that does not exist.
Subscribers - Oct 43 min read
The SMRC Is Reviewing Claims You Billed in March
Fifteen projects are open at the Supplemental Medical Review Contractor. The oldest reaches back to January 2023, the newest takes three months of 2026, and the median window under review is now exactly twice as wide as the completed record's.
Free - Oct 45 min read
How Your Telehealth Code Now Decides the Patient's Bill
CMS issued Transmittal 13975 on Tuesday, two days before its own effective date, under 'there are no policy changes associated with this instruction,' with no provider education and no impacted contractors. Diff it against the version it replaced and the manual had been telling rural health clinics that their telehealth authority expired on December 31, 2025, and that the Part B deductible was twenty percent of charges. It is $283, and on the first telehealth visit of the year that is the difference between collecting $19.51 and collecting the whole $97.53.
Subscribers - Oct 34 min read
The $526 on the Other Side of the Premium Cut
CMS announced the 2027 Medicare Advantage landscape as a premium story: average monthly premiums down 16.5%. The file it posted two days later says the in-network out-of-pocket maximum rose $525.86 a head across 16.5 million enrollees, $8.67 billion of additional maximum in-network liability, and we have the increase broken out by parent organization.
Subscribers - Oct 34 min read
How an Eye-Tracking Test Got Its Own G Code
Until Thursday, the three letters asd in Medicare's payment files meant atrial septal defect. CMS established HCPCS G0685 effective October 1 for an algorithm-based assessment of autism likelihood from eye-gaze data, priced it at $135.93 in the hospital outpatient department, and left the physician office side to the MACs. The device the descriptor describes has been FDA-authorized since 2022, and in March it got the age range that makes the code worth having.
Free - Oct 35 min read
Everything the Corrections Fixed That Wasn't a Rate
Five FY 2027 rate books were corrected in three days, and the rate changes were the small part: one of those documents fixed a day-one payment factor that three straight final rules printed wrong, worth $9.12 on every psychiatric admission. Also this week, a Federal Register notice whose entire content is a link CMS forgot, a hospice condition of payment that started Thursday on a ninety-day grace period, and UnitedHealthcare's October clock.
Subscribers - Oct 23 min read
Why Two Medicare Files Disagree About Which Codes Are Dead
The October ASC addenda went up at 4:49pm Thursday, after the rates in them took effect and almost eight hours behind the hospital outpatient file. The two releases came out of the same quarterly update and they disagree about 19 codes: the ASC file keeps 12 that CMS deleted from the OPPS file and deletes 7 the OPPS file kept. The change request that is supposed to describe the ASC file has not issued.
Free - Oct 27 min read
How to Collect a Coinsurance CMS Won't Let You Compute
CMS finalized the GLOBE Model this morning. Starting April 1, 2027, about a quarter of Original Medicare patients will owe something between 2% and 12% on certain Part B drugs instead of 20%, decided by the ZIP code on file at CMS, determined inside claims processing, and closed to appeal. A hospital asked for the patient list. CMS said the ZIP codes are enough.
Subscribers - Oct 26 min read
Every MAC Starts Publishing Its Probe Results in November
CMS issued CR 14616 on Wednesday. From November 2 every A/B MAC and every DME MAC has to post its Targeted Probe and Educate results each quarter, and the floor is three denial reasons per open topic. The rate those probes are graded on is dollars denied over dollars reviewed, it has not been revised since 2017, and nothing in the new requirement makes anyone publish it.
Subscribers - Oct 16 min read
The Downcode Record: September Only Moved Money by Accident
CMS published no new payment rule in September, proposed or final. It published five corrections instead, the last two this morning, hours before the rates they fix take effect, and all five trace to one hospital that was filed as a rural emergency hospital and isn't one.
Subscribers - Oct 14 min read
The 39 Codes WISeR Stops and the 379 It Touches
CMS publishes the entire scope of its new prior-authorization model in one free guide, now on its seventh version: thirteen service families, 39 codes that need the authorization, 64 ICD-10 indications, and 379 associated codes that get paid or denied on somebody else's decision. Here is what is actually in it.
Free - Oct 14 min read
Nothing but Drugs Moved in the October Rate Book
The October OPPS Addendum B went up at 8:58 Thursday morning, the day its rates took effect, from a file CMS finished on September 28. We diffed it against July: 571 payment rates changed and every one of them is a drug or biological, 510 of those numbers were already public on September 17, and C9312 finally has a price.
Subscribers - Sep 306 min read
Who Had the October OPPS Update on August 12?
Transmittal 13978 posted Tuesday afternoon, two days before the quarter it governs. Its own first paragraph says the instruction was finished on August 12 and held back as sensitive. The same thing happened in January, April and July, and the October rate book still isn't up.
Subscribers - Sep 306 min read
How a Wage Index Error Travels Through Five Rate Books
CMS corrected two more FY 2027 payment rules this morning, both traced to the single hospital record that forced Tuesday's inpatient correction. Hospice got recalculated rates, a reissued contractor instruction and a wage index file republished on Tuesday. Skilled nursing got recalculated rates and a wage index file on cms.gov still stamped July 29. Inpatient rehab and inpatient psych price off the same index and have no correction at all, with the fiscal year opening Thursday.
Subscribers - Sep 303 min read
CMS Is Running Nineteen Payment Models and Updating Three
The CMS Innovation Center publishes a dated log of everything it posts about its own models, and the catalog promises a weekly refresh. Through nine months of 2026 that file has thirteen rows, the fewest in fifteen years, and ten of them are evaluation or final reports, seven on models that have already stopped. TEAM, the mandatory episode model that has been running since January 1, has not appeared in it since April 2025.
Free - Sep 294 min read
Who Takes the Denial After the Second Appeal Fails?
Revecore put in-house attorneys behind the denials that survive two rounds of appeal letters, and named ERISA as one of the five categories it will work. The federal rule those appeals run under gives the appealing side 180 days and gives the plan no more than 60 to answer, which is most of the reason the money is still there.
Free - Sep 294 min read
The 746,240 Fee Amounts Medicare Left Alone
CMS issued the October DMEPOS quarterly update this morning, effective Thursday. We diffed the year's three published fee files against each other first: not one fee amount has changed all year, and the money moved somewhere else entirely.
Subscribers - Sep 295 min read
CCN 250078 Rewrote Everyone's 2027 Rate Book
CMS filed a sixteen-page correction to the FY 2027 inpatient rule Monday morning. Two provider records were wrong, and fixing them moved the relative weights, every wage index, the standardized amounts, the capital rate, the outlier threshold and Factor 3 for all 2,274 DSH hospitals, effective Thursday. Also this week: two add-on payment code lists were wrong, hospitals stop attesting a year earlier than the printed rule said, and the October outpatient rate book is still missing.
Subscribers - Sep 286 min read
The Outpatient Quarter Opens Thursday Without a Rate Book
CMS has issued 253 transmittals this year, including seven that tell contractors how to handle the October 1 quarter. The October OPPS update, the October ASC update and the October outpatient code editor are not among them, and 45 new HCPCS codes go live Thursday, three of which have no published price anywhere. Eleven of the last twenty-one outpatient instructions already reached contractors after the quarter they govern had started, so this is closer to the pattern than to an exception.
Subscribers - Sep 283 min read
The 12,431,122 Enrollees CMS Took Out of One Footnote
CMS replaced the CY2020 and CY2021 Medicare Advantage inpatient workbooks on Thursday afternoon. Five cells moved in each, four of them a link, and the fifth is the enrollee count every per-1,000 rate in the table divides by. For two data years it was the fee-for-service count instead.
Free - Sep 286 min read
How One October Edit File Got Issued Five Times
CMS put the October front-end edit set out on April 16 and has rescinded and replaced it four times since, most recently this afternoon. The last two re-issues both land in the same segment of the claim status inquiry: two edits off by one element on September 18, eleven byte offsets off by exactly eight today. It takes effect Thursday.
Subscribers - Sep 274 min read
Who Appeals the Other 128,597 Denials?
Centene's five California plans published their CY2025 prior authorization metrics because CMS-0057-F made them. Their own filings say 47% of appealed denials got reversed, and 1.6% of denials were ever appealed.
Subscribers - Sep 275 min read
Thirteen Years of ASP Checks Bought Medicare $78 Million
OIG's annual price-substitution brief landed Thursday: $1.6 million saved on 2024 sales data, against $61 billion of Part B drug spending, and 31 drug codes it could not evaluate at all because the manufacturer-reported AMP data looked wrong. Everything else that published this week counts things rather than pays for them, and the October outpatient and ASC rate files are still missing with four days to go.
Subscribers - Sep 273 min read
The Other NPI List Your Claims Get Checked Against
CMS publishes the roster of practitioners its Part A shared system will take as attending and rendering on an institutional claim: 2,065,071 NPIs, rebuilt every 3.5 days, 344 editions still on the shelf. It is not the ordering and referring file, and on Thursday's builds the two rosters were 212,029 names apart.
Free - Sep 267 min read
What Treasury Sends Back When It Finds Your TIN
CMS filed a notice on Friday re-establishing its computer match against Treasury's Do Not Pay system, for a 36-month term starting around October 19. It sends twelve fields about every provider who bills Medicare and gets forty-nine back, two of which set an enrollment effective date in the past. The comment period closes a week after the program starts.
Subscribers - Sep 263 min read
Medicare's Opt-Out List Is Mostly a Mental Health Directory Now
CMS published the August 2026 opt-out roster on September 16: 57,780 providers, and 61% of them are behavioral health. Two specialties that could not bill Medicare at all before January 2024 supplied 14,631 of the 25,394 names the file has added since, and almost a third of every marriage and family therapist Medicare holds a record for is on it.
Free - Sep 266 min read
How a $3,240 Test Becomes Incidental to a $207 Biopsy
Aetna's October bulletin adds one edit to its Medicare book: from January 1, 2027, two molecular transplant rejection codes get denied as incidental when a biopsy lands on the same date. Medicare already has that rule, with an appeal attached. Aetna named two of the seven codes the policy covers, and the two it named carried $18.8 million of the $132.6 million those labs billed.
Subscribers - Sep 254 min read
The Nudge in Your EHR Is Now a Query
AHIMA and ACDIS rewrote the compliant query practice brief on September 1 and published it free. The 2026 edition pulls prompts, nudges, advisories and AI-drafted query language inside the compliance line, hands accountability for all of it to the organization rather than the vendor, and tells external reviewers the brief is not a basis for denying a claim.
Free - Sep 254 min read
The $471 a Case CJR Took Back in Its Final Year
CMS published the final evaluation of Comprehensive Care for Joint Replacement this month. The model saved Medicare $180 million across its three-year extension, and the component that grew was the check hospitals wrote at reconciliation: $78 per episode in PY 6, $471 in PY 8. CJR-X goes national and mandatory on January 1, 2028 with a projection that books 53% of its savings that same way.
Subscribers - Sep 255 min read
How October Got Lighter and January Got Crowded
Seven days before its effective date, CMS pulled a national coverage determination out of the October coding update and parked it in an April 2027 change request. Seven of September's sixteen transmittals now land on January 4, Aetna's October bulletin is almost entirely about January 1, and the October outpatient and ASC rate files still are not posted.
Subscribers - Sep 245 min read
Why 102 Lab Codes Won't Reach Their New Price by 2029
CMS repriced the lab fee schedule on Monday off 2025 commercial rates instead of 2016 ones: a 16% average cut across 1,528 test codes, effective January 1. The 15% annual cap means most of the schedule lands short, 102 codes never arrive at all, and comments close October 21.
Subscribers - Sep 244 min read
The 1.2 Million Who Kept Medicare Advantage and Dropped Its Drug Plan
CMS's monthly enrollment file shows standalone PDP enrollment up 1,466,468 in a single month and MA-PD down 1,170,558, only the second monthly MA-PD decline in thirteen years. Medicare Advantage itself grew across the same step, which means the medical card and the drug card just stopped being the same payer for well over a million patients.
Free - Sep 247 min read
CMS Just Asked to See the Side Letters
A request for information published this morning opens the first federal attempt to define reasonable and relevant pharmacy contract terms since the phrase entered the regulation in 2005. Ninety-seven questions, running to rate sheets, unwritten understandings between affiliated entities, deemed acceptance, extrapolated recoupments, white bagging and 340B. Comments close November 23, and the standards bind plan year 2029 contracts.
Subscribers - Sep 234 min read
Why Does a Tier 1 Steroid Need a Prior Auth on Half of Part D?
CMS refreshed its free formulary file this week. It carries the prior authorization flag for 6,170 drugs across all 5,518 Part D and Medicare Advantage drug plans, and prednisone is flagged on 2,569 of them. Fifty-six drugs are flagged on every plan in the country, and CMS's own manual explains why. The 2027 edition lands October 15.
Free - Sep 234 min read
How a January Enrollment Decides Who You Can Bill in February
5,865,920 Medicare beneficiaries have Part A and no Part B, the lowest share in the 162 months CMS has published. The file that dropped this morning shows where they went: since 2023 the column drains every January and February, and this year's drain was the biggest yet at 243,170 people. Here is the state-level spread your registration desk is working against, and the re-verification window it opens.
Subscribers - Sep 234 min read
Everything That Moved This Week Came From One Payer
Since Friday the 18th, CMS has published exactly one document to the Federal Register, issued no transmittals, and revised nothing in the coverage database for twelve days. UnitedHealthcare posted six provider notices in the same stretch, two of them rewriting how you verify coverage in 2027. Here is the whole week, with the October 1 clock still running.
Subscribers - Sep 226 min read
Which of Your 2026 Patients Was Never Actually Covered?
CMS cancelled 315,000 Plan Year 2026 Marketplace policies on August 31, covering more than 760,000 people. Under 45 CFR 155.430 a cancellation reaches back to the original effective date, which means those policies were never in force at all. The reason your aging report didn't move is one clause in the rule CMS filed this morning: it picked the enrollments where issuers could not identify a claim.
Subscribers - Sep 224 min read
The 118 Lab Codes Medicare Still Hasn't Priced
CMS posted the October clinical lab fee schedule at 8:08 this morning, nine days before it starts paying. It adds 39 codes at $0.00 and changes the price of nothing, which makes 118 codes on the schedule that carry a local pricing indicator and no national rate. All 32 of the ones that arrived on January 1 are still sitting there.
Free - Sep 226 min read
How Four MACs Un-Deny a Test They Refused for Eleven Years
On October 12, Factor V Leiden and prothrombin genetic testing stops being a blanket non-coverage policy in 28 states and becomes a policy with 1,171 payable diagnosis codes. The claims file shows what eleven years of non-coverage did to the volume, the new billing article shows where the real gate sits, and three of the four contractors have scheduled the old policy's retirement. One has not.
Subscribers - Sep 215 min read
The Six Weeks Your Coverage Database Isn't Showing You
The Medicare Coverage Database has published nothing for ten days, and behind the silence 75 local coverage documents are already final with effective dates between Sunday and November 1. Four of them are new multi-jurisdiction LCDs whose comment periods closed weeks ago: allergy testing gets a hard cap at 70 percutaneous tests, peripheral nerve injections lose sedation, and MolDX draws two new lines on genetic panels.
Subscribers - Sep 214 min read
Medicare's Order List Grew by 1,260 and 435 Providers Lost Authority
CMS rebuilds the Order and Referring file twice a week, and the only number anyone looks at is how long it got. Between the 09/17 and 09/21 builds it got longer by 1,260 NPIs. Underneath that, 196 providers came off it entirely and another 239 kept their row while a flag switched off, which is the half no presence check will catch.
Subscribers - Sep 214 min read
Four Health Systems Stopped Retyping Orders Into Payer Portals
On August 17 four health systems and three payers went live on the real-time prior authorization check that Medicare Advantage, Medicaid and marketplace plans all have to support by January 1. The specification behind it is free to read, it names the exact answers a payer can give at order entry, and one of those answers lets an authorization number ride straight to your 837.
Free - Sep 206 min read
What Happens to the Overpayment After You Close the PTAN?
Transmittal 13966 gives HIGLAS a PROVIDER-TERMINATED status at the customer level on January 4, so one verified termination flips every open receivable the entity owns at once. For a provider still enrolled, the Intent to Refer letter is a day-66 event. For one that closed, it goes out the day the MAC confirms it, and Treasury has the debt 66 days after that.
Subscribers - Sep 203 min read
Retroactive Payment Didn't Bring the Telehealth Visits Back
CMS added two quarters to the Medicare Telehealth Trends file on September 17, and they are the first public look at the six-week lapse. Telehealth's share of eligible users fell to 10.76 percent in Q4 2025, the lowest quarterly reading since the quarter the pandemic expansion began, and Q1 2026 came back under every first quarter of the last three years. Congress paid those claims in full.
Free - Sep 206 min read
How Twenty Claims Become a $12.4 Million Demand
OIG posted a hospital compliance audit on September 17 asking Methodist Hospital in San Antonio to refund $12.4 million. Twenty inpatient rehab claims produce 99.5 percent of the estimate behind that number, and the sixty acute inpatient claims in the same sample extrapolate to about ten thousand dollars. Three days earlier the same audit series asked McLeod Regional for $38,676, because its sampling frame had no rehab stratum in it.
Subscribers - Sep 195 min read
What Can a Surveyor Cite You For That Didn't Exist on Thursday?
CMS rewrote the hospital and critical access hospital survey tags for emergency and obstetrical readiness on Friday, effective Friday, with no notice period and no provider education. Also this week: UnitedHealthcare put prior authorization back on eleven oncology J-codes, the October EDI edits got reissued for the third time, and the Coverage Database went eight days without publishing anything.
Subscribers - Sep 194 min read
The Audit Queries OIG Published on Purpose
The Inspector General put the SQL from its Medicare Advantage risk adjustment audits on the open web, CMS table names and all, with a comment telling you where to swap in your own member ID. Eight high-risk code groups, 3,780 transposition pairs, and seven telehealth thresholds with the median provider printed next to each one. Nothing behind a login.
Free - Sep 194 min read
Almost Half That Biosimilar Payment Is the Brand's Price
CMS posted the final October Part B payment limit file on September 17. Thirty-six biosimilar codes carry an add-on computed on the reference product's ASP, not their own, and on Q5116 it is 46.1% of the whole payment. We priced all thirty-six, and put a date on the cliff twelve of them hit.
Subscribers - Sep 183 min read
Why Medicare Scored 22,496 Clinicians on Nothing and Paid Them in Full
CMS published every 2024 MIPS final score. 22,496 clinicians were scored on zero performance categories and landed on exactly 75.00 for a neutral adjustment, while 4,771 landed on a flat zero and are taking negative 9 percent on every Part B claim they bill this year. 17.62 percent of the podiatrists in the file are in that second group.
Free - Sep 186 min read
Which Prenatal Code You Bill Now Depends on the Card
Aetna told its network to switch to E/M and modifier TH for prenatal visits on or after September 1. Cigna, three weeks later, told its network specifically not to. Same patients, same date, and the global OB codes both instructions lean on stop existing in 105 days.
Subscribers - Sep 185 min read
Medicare Advantage Got 4% of UnitedHealthcare's 30%
UnitedHealthcare said on September 1 that it would drop 30% of prior authorization requirements on October 1. We counted all five code files against each plan's own September list: Oxford 40.8%, commercial 29.7%, Individual Exchange 29.7%, Medicare Advantage 4.0%. D-SNP members get four fewer codes than Medicare Advantage members, and those four carry 90% of the list's weight.
Subscribers - Sep 174 min read
Where the Lab Work Goes After the Practice Sells
A nonprofit sitting on a billion commercial claims a year went and counted what happens to coding intensity and site of service in the two years around a physician acquisition. The lab share moved four times faster than the imaging share, and reading the whole thing costs nothing.
Free - Sep 175 min read
The Contract Nobody Has to Re-Enroll For
CMS awarded the Jurisdiction H A/B MAC workload this week and the transmittal's whole point is that nothing about it changes: same workload identifiers, same FISS roll-ups, same BSIs, no provider education. Meanwhile eight coverage documents went live across four MACs this morning with no announcement at all, and four of them repriced a facet joint code pair.
Subscribers - Sep 174 min read
The 2,226 ZIP Codes Medicare Took Off Auto-Pay
CMS opened the 2027 HPSA bonus file on September 15 with CR 14604. Diffing the last three editions shows 2,226 primary care ZIP codes came off the automated list in a single update, 2,017 are still off, and the 10% bonus for 7,025 physicians in them now depends on a modifier the MACs sample.
Subscribers - Sep 166 min read
Medicare's Lab Edits Find Out About October in January
Transmittal 13952 landed this morning with 172 code edits across 21 laboratory NCDs, every one of them effective for dates of service starting October 1 and none of them loaded into the shared systems until January 4. Twenty of those policies spend 95 days denying what they are written to cover. One spends 95 days paying what it is written to deny, and CMS has already said it will not go looking for that money.
Subscribers - Sep 166 min read
How Much Does a Denial Have to Be Worth to Reach a Judge?
CMS published the CY2027 appeal thresholds this morning: $200 to reach an ALJ, and judicial review crossing $2,000 for the first time. The $200 has not moved in two years, and the regulation under it computes that number six different ways depending on what you are appealing. Which one applies decides whether 97 percent of your Part B volume can be appealed at all.
Subscribers - Sep 163 min read
Fifty Units of Fluorouracil Where One Used to Do
CMS posted the October 2026 HCPCS file on September 10. It terminates fifteen codes on September 30, including a leucovorin code that has been in the book since 1982, and brings nine of the drugs back the next morning under new numbers with smaller billing units. The quantity on the claim has to move by 2x, 10x, 20x or 50x depending on the drug.
Free - Sep 153 min read
Who Got Drafted Into Medicare's Mandatory Specialty Model?
CMS posted the final CY2027 roster for the Ambulatory Specialty Model at 2:15 this afternoon. It names 5,533 clinicians in 232 CBSAs, and their CY2024 Medicare billing puts $118.6 million a year under a plus-or-minus 9 percent adjustment that nobody on the list volunteered for.
Subscribers - Sep 154 min read
Somebody Already Sorted All 75,725 Diagnosis Codes for You
AHRQ's Clinical Classifications Software Refined maps every ICD-10-CM code into 553 clinical categories, picks which one to use as the principal diagnosis, and flags 10,843 codes that cannot be one. It is a free CSV with no login, and the release that covers October's new codes is the next one.
Free - Sep 153 min read
Six Days Left on the Only CMS Rule Still Taking Comments
The CY2027 physician fee schedule docket shut on Monday at 44,287 comments, two thirds of everything CMS has drawn all year. What is still open is a 38-page Medicaid financing rule sitting on 31 comments, and the coverage database has not published a MAC change in nine days.
Subscribers - Sep 145 min read
The Coinsurance List CMS Stopped Publishing
Eighty-four Part B drug codes carry a reduced patient coinsurance from October 1, down from 107 in the current quarter. CMS has not published the quarterly list since March 2025, so the only source is a Notes column in a spreadsheet, and we diffed it: 31 codes out, 8 in, and a modeled $38.6 million a year of patient relief gone.
Subscribers - Sep 143 min read
Medicare's Opioid Clinic List Gained 114 Names the Hard Way
CMS republishes the roster of Medicare-enrolled opioid treatment programs every week. Across 41 monthly snapshots since May 2023 it added 529 NPIs and dropped 415 to finish 114 ahead, and the stretch from August 2025 to January 2026 was five straight months of decline. Here is the whole series, plus the $229 million of CY2024 billing sitting on top of it.
Free - Sep 146 min read
How Medicare Fits a Second Conversion Factor Into One Byte
Transmittal 13912, issued this morning, renumbers the MPFSDB record layout end to end and turns two bytes of filler into the QPP pricing indicator. The two conversion factors have been paying since January 1 and sitting in the public RVU files since December 22; the manual that describes the file catches up on November 16.
Subscribers - Sep 134 min read
What Happens When 637 Inpatient Procedures Land on 23 APCs?
CMS proposes taking 637 services off the inpatient-only list on January 1. It published the destination of every one of them, and 566 land on a comprehensive APC, where the whole claim collapses into a single rate and eight groups absorb two-thirds of the volume.
Subscribers - Sep 134 min read
The Committee That Owns Your Taxonomy Code
Eight hundred and eighty-three ten-character codes decide how every NPI in the country gets classified, and a twenty-organization committee has maintained them since 2001. Its July release added no codes, changed eleven rows, and takes effect October 1.
Free - Sep 135 min read
Only 80 of 918 Part B Drug Prices Held Still
Medicare's October drug payment limits posted on a Tuesday with no announcement and no transmittal. We diffed them against July: 799 codes repriced, 38 new, 10 retired, two antivenoms back on the books, and a Notes column that names which codes are priced off AMP instead of ASP.
Subscribers - Sep 124 min read
Who's Left to Run Medicare's Home Infusion Benefit?
CMS proposes to open the DME benefit to infusion pumps a patient cannot run alone, effective April 1, 2027, and the second of the three statutory criteria requires a qualified home infusion therapy supplier. There are 321 of them left in the country, the lowest count on any file CMS still publishes.
Free - Sep 127 min read
How a Rural Add-On Dies in the Provider Specific File
CMS issued the FY 2027 IPPS claims instruction on Friday, and it revises no manual section. It tells every MAC which two PSF fields to blank on January 1, when 589 low-volume hospitals and 81 MDHs lose $352 million between them, and the letters that decide who keeps the money are due before December.
Subscribers - Sep 125 min read
$841 Million Rides on Where the Attending Was Standing
CMS reissued the teaching physician booklet with a line that reads like permanent virtual supervision. The flexibility covers only three-way telehealth visits, and every GC line you bill still attests to where the attending physically stood.
Subscribers - Sep 114 min read
Four MACs Just Closed the Nerve Block List
Thursday's coverage database refresh carried a finished LCD nobody sent you: Peripheral Nerve Injections and Procedures for Chronic Pain, identical across CGS, Palmetto, Wellpoint Federal and WPS, notice opened September 10, paying rules effective October 25. Fourteen codes, 43 covered diagnoses, and anything not on the list is non-covered. Plus six MACs quietly deleting the same sentence, a 115-day retroactive coverage expansion, and 6,687 diagnosis codes that stop supporting an injection.
Subscribers - Sep 114 min read
Eleven Years On, Modifier 59 Is Still Gaining
CMS built four modifiers in 2014 to retire the most abused one in Part B. The CY2025 claims summary says providers went the other way, and that on the same code the swap moves your denial rate by as much as forty points.
Subscribers - Sep 114 min read
California Kept the Notes on 42,749 Denied Appeals
The Department of Managed Health Care has published every independent medical review it has decided since 2001, with the physician reviewer's full written reasoning attached to each one. We pulled all 42,749 rows. The plan lost 72.3% of them last year, 81.7% of the pharmacy cases, and 91.5% of the weight-control drug cases.
Free - Sep 106 min read
Why One Prior Authorization List Got 90 Days and the Other Got 35
Forty orthosis and bone stimulator codes become prior authorization codes on October 15 for any DMEPOS supplier Medicare considers new. The list lives in a four-page PDF, the Federal Register has never printed the words probationary prior authorization, and the regulation CMS cites counts four ways to become new when the announcement names two.
Subscribers - Sep 106 min read
One Price for 283 Telehealth Codes, and an Edit if You Pick Wrong
RHCs and FQHCs stop billing G2025 on October 1 and must report the individual CPT code for every distant site telehealth service. Payment stays a flat $97.53 no matter which of the 283 codes they pick, 162 of the 258 priced ones pay less than that on the fee schedule, and a wrong code now draws IOCE edit 139 and a returned claim.
Subscribers - Sep 103 min read
How the Vaccine Price File Changed Without Changing Its Name
CMS filled in six blank COVID-19 payment limits on September 1 and left the August 27 issue date stamped on the file name. Same URL, same file name, different prices. If you pulled the file the evening it posted, you are still holding the blanks, and the six codes came back 20.5 percent above last season.
Free - Sep 94 min read
Two Fluorouracil Codes, $740 Apart
CMS posted the October preliminary Part B payment limit file Tuesday afternoon. It deletes ten J codes, adds thirty-eight, reprices 799 of the 879 that carry over, and splits three ancient generics into a generic code and a manufacturer-specific one priced up to 380 times higher. Zoledronic acid is up 425.83%. Two antivenoms start paying again and a cyanide antidote stops.
Subscribers - Sep 94 min read
The SNF Exclusion List Has Been Wrong Since January
Forty-four therapy codes sit on the CMS file that tells an outside provider to send the claim to the Part B MAC for a resident in a covered Part A stay. CMS says they never belonged there, pulls them October 5, and will not go looking for the claims that already paid.
Subscribers - Sep 93 min read
CMS Publishes the List of Everyone Allowed to Audit You
The Review Contractor Directory names, for all 56 states and territories, every contractor that can send your practice a records request: the MACs, the Recovery Auditors, the program integrity contractors, with addresses, fax numbers and whether each one takes electronic submission. Ten regional audit territories, seven companies, and three maps that do not line up.
Free - Sep 85 min read
The Sentence Medicare Left Open in 1978
Medicare's national coverage determination on therapeutic embolization is one sentence long and has not been touched since December 1978. UnitedHealthcare just wrote the list that sentence never contained: hemorrhoids and musculoskeletal pain are unproven from December 1, across the commercial, exchange and Medicaid books. The code it lands on pays $6,675 in the office, and 94 cents of every dollar is spent before the claim leaves the building.
Subscribers - Sep 87 min read
The Fee Schedule Arrives the Day It Starts Paying
Aetna is updating its Market Fee Schedule in nine states on October 15 and November 1. The bulletin announcing it went up on August 13. The rates themselves publish on the effective date, which is the one number you need and the one you do not get, and in Maine and Washington the statutes say what you are owed instead.
Subscribers - Sep 83 min read
Louisiana Orders Home Ventilators Seven Times as Often as Utah
E0466 is the fifth largest DMEPOS code in Medicare and the most expensive per patient of the top five, at $9,923 a year. The rental rate barely moves across the country. The ordering rate moves 7.6x, and on October 28 every one of those orders needs a face-to-face encounter on file.
Free - Sep 73 min read
What Is a Perfect MIPS Score Worth?
CMS modeled its own quality program for the 2029 payment year and the ceiling came out at 1.34 percent. The floor is negative 9. The median solo practitioner who submits nothing scores 24.70, which is an 8.05 percent cut on every Part B payment, and comments close September 14.
Subscribers - Sep 74 min read
CMS Wrote the Test Your Price File Has to Pass
The agency maintains an open-source validator for hospital machine-readable files, public domain and free, and shipped seven releases of it this year to keep up with its own new rule. It also publishes every enforcement letter it has sent since 2021, and April 2026 is the biggest month in that file.
Free - Sep 74 min read
42,968 Comments on One Rule and Nine on Another
CMS filed one document with the Federal Register in four days. Meanwhile the CY2027 physician fee schedule docket has taken 42,968 comments, two thirds of everything filed on CMS rulemaking since May, and it shuts Monday. The RAPID device coverage pathway CMS proposed in August has nine, and it stays open until October 13.
Subscribers - Sep 64 min read
Your LCD Feed Fired 406 Times and Meant It 50
Medicare published 406 local coverage determination revisions with a 2026 effective date. We classified every one off the contractor's own revision note, and 50 of them changed coverage, codes or requirements. The other 356 are a corporate rename, a document merge, and a lot of bibliography links.
Free - Sep 67 min read
What Makes an Organ a Medicare Organ?
OIG put $379.9 million on CMS's presumption that any organ a transplant center ships out the door went into a Medicare patient, and said the statute forbids it. Four weeks earlier CMS finalized that same presumption for organ procurement organizations, effective October 2028, and booked $1.28 billion of savings against it.
Subscribers - Sep 66 min read
Medicare Priced Your Remote Monitoring Program Twice
The CY2027 physician fee schedule proposed rule carries a downloads-folder file showing what practice expense RVUs would be with the caps switched off. On 99454 the two numbers are $41.05 and $9.52. Nine thousand of the file's 9,658 lines disagree with Addendum B, and comments close September 14.
Subscribers - Sep 54 min read
Two Curl Commands to the Whole Coverage Database
CMS runs a free API over the Medicare Coverage Database, no key and no registration, and it publishes the declared reason behind every LCD revision. We spent an afternoon in it: of 183 LCD revisions last quarter, 98 declared an administrative reason and 27 declared a change to policy content.
Free - Sep 55 min read
Nobody Told You What Changed in Your Part B Drug Policy
UnitedHealthcare's September Medicare Advantage bulletin lists Medications/Drugs (Outpatient/Part B) as revised effective September 1, then prints the orthopedic change log underneath it: Girdlestone, 27299, 25449, 29840, 27122. Eight CGS coverage determinations took effect the same week with the synopsis field blank. The rest of the radar is the step therapy change that did get written down, Cigna rewriting August on September 4, and Aetna's claim edits landing December 1.
Subscribers - Sep 53 min read
75,001 Exclusions Your NPI Screen Will Never Match
OIG's exclusion file carries an NPI column, and 75,001 of its 83,842 active records leave it blank. Coverage runs 86.8% for physician assistants and 2.6% for nurse aides, which is backwards from where the civil money penalty actually sits. Four entities settled employment-exclusion cases with OIG this year for $406,151, and every one of them self-disclosed.
Subscribers - Sep 46 min read
The Drug Went Over the Counter. The NDC Never Did.
OIG found $587.7 million in Part D payments for five drugs whose brand-name versions went OTC years earlier. We ran the same test against today's NDC Directory: fifteen of those prescription listings are still live, and naloxone has eight more sitting outside the audit window.
Subscribers - Sep 44 min read
How Many Vessels Did Medicare Think You Had?
CPT rebuilt lower-extremity revascularization around 46 codes in January. CMS capped every one of the add-ons at a single unit per day in April, and the October file raises all 24 of them without saying why.
Free - Sep 46 min read
Fourteen Days of Silence Opens a Medicaid Audit
CMS revised nine sections of the Medicaid Program Integrity Manual on Thursday and told its contractors the change does not affect providers. It gives your state Medicaid agency 14 calendar days to answer a UPIC vetting request, opens the investigation if nobody answers, and takes CMS out of reading your response to the findings. Effective October 5.
Subscribers - Sep 35 min read
CMS Reissued Thirteen Pages to Change One Digit
Transmittal 13943 rescinds and replaces the October SNF consolidated billing update CMS published on August 21. A full-text diff of the two versions turns up exactly one substantive change: a year in the policy section, 2025 corrected to 2026. Everything else in this radar is what did not publish, including five straight days with zero coverage-policy changes across all twelve MAC jurisdictions.
Subscribers - Sep 34 min read
California Doubled Its Share of Medicare Home Health
CMS posted the CY2025 home health utilization file on September 1, the same claims year it is using to set CY2027 rates. Across all 55 jurisdictions, California is the only one sending more visits per patient than it did in 2017, and it now books 22.9% of the program on 14.6% of the patients. Here is what the proposed 3% cut takes out of each state.
Subscribers - Sep 27 min read
Who Can Use Medicare's New Hospice Telehealth Code?
CMS reissued its hospice telehealth instruction today, deleting one edit and leaving everything else alone. G0679 goes live January 1 for recertification encounters done by video. The statute the change request cites switches that option off for any patient in an area under a hospice enrollment moratorium, and CMS put the entire country under one on May 13. The instruction does not mention it.
Subscribers - Sep 26 min read
The Fourth Prenatal Visit Is Worth $194
Aetna's August bulletin told practices to bill prenatal visits as E/M for every patient expected to deliver in 2027. The September bulletin adds the condition August left off: only when three or fewer visits land before January 1. The threshold is the AMA's, the instruction took effect Tuesday, and it prices the same eleven-visit pregnancy twelve different ways.
Subscribers - Sep 24 min read
The Benchmark You Are Allowed to Bring to IDR
FAIR Health said in August that its allowed-amount data can be put in front of a certified IDR entity. The federal rule bars the three benchmarks a billing office reaches for first, and the nonprofit's free public site already shows the 20th through 90th percentile of what plans actually pay.
Free - Sep 16 min read
The Downcode Record: Everything Ships in Thirty Days
CMS finalized one payment rule in August and it was the year's largest: FY 2027 hospital rates worth $2.1 billion, plus $779 million in new technology add-ons, all live October 1. Two months of final rules now total $4.75 billion. The proposals that take $5.7 billion back out closed for comment on August 31, and nobody gets to argue about them again.
Subscribers - Sep 13 min read
How Much of Medicare's Revalidation List Is Already Expired?
The September edition of the Revalidation Due Date List posted with 2,943,135 rows, and 277,795 of them carry a real date. Only 44,349 of those dates are still in the future, and 21,885 land before December.
Free - Sep 13 min read
1,539 New Bundles No Modifier Will Open
CMS posted the October correct-coding change lists this morning. The practitioner file adds 4,249 procedure-to-procedure edits and removes 14, and 1,539 of the additions carry modifier indicator 0. The heaviest concentration on any established CPT code lands on percutaneous fistula creation, where a same-session angioplasty worth $4,224 stops being billable at all.
Subscribers - Aug 315 min read
Medicare's Fraud War Room Suspended a Fifth as Much This Year
CMS's Fraud Defense Operations Center suspended more than $1.8 billion in 2025 and $371 million since January, from a larger number of providers. Here is the service-line split behind the drop, what a suspension is now worth, and where the $1.6 billion in lab enforcement CMS announced Friday actually came from.
Subscribers - Aug 315 min read
How a Vaccine Gets an NDC, a Code, and No Price
CMS posted the 2026-2027 seasonal vaccine payment file on Friday evening. Nine influenza codes arrived with a number, every one of them higher than the July quarterly file, and one of them new at $171.21. The six COVID-19 codes arrived with a manufacturer, a national drug code, an August 27 effective date, and the letters TBA where the payment limit goes. Also in this radar: the FY2027 Medicare Code Editor came out of the proposed rule six codes heavier, and the rest of the federal machine published nothing at all.
Subscribers - Aug 314 min read
CMS Already Published the Error Rate on What You Bill
The Medicare Learning Network keeps 57 service-line denial dossiers, each one carrying the 2024 improper payment rate, the projected dollars, and the exact mix of reasons the money failed. Two of them surfaced in MLN Connects this month. The other 55 have been sitting there the whole time.
Free - Aug 303 min read
Why Your October Procedure Codes Expire in March
CMS dates the FY2027 procedure code set October 1 through March 31, not through September. The April 1 mid-year update has grown from 7 codes to 80, it ships its own grouper, and one new cardiac family carries a $10,261 DRG gap.
Subscribers - Aug 306 min read
The Face-to-Face You Have to Produce Five Years Later
CMS wants to stop requiring a new face-to-face encounter for identical DMEPOS replacements, and says the fiscal impact cannot be estimated. On audit you still produce the original encounter, which can be 66 months old, from records nobody has to keep past month 84. Comments close tomorrow.
Subscribers - Aug 303 min read
The 15 Codes That Stay in the Book and Stop Working
The FY2027 diagnosis file adds 190 billable codes, the second-smallest annual haul in six years, and every summary you read this month will lead with that number. The one that reaches your denial queue is 30, and half of those codes never leave the tabular list at all.
Free - Aug 295 min read
What Happens When 66 New Codes Arrive Without a Price?
The October physician fee schedule update went to your MAC on August 21 and to the public on the 27th. Inside: 112 code records, six of them nationally priced, 58 new Category III codes the contractor prices off your operative report, six skin substitutes joining the $127 sheet rate, ten drug codes going invalid with three of their replacements dosed in different units, and one record back-dated to May in a year CMS just told contractors not to reprocess.
Subscribers - Aug 297 min read
The Translator Swap Starts Next Week
CMS is replacing the EDI translator at every A/B MAC with one centralized system, one jurisdiction a week from September 7 through mid-November. The change request that authorizes it lists provider education as None. The same quarter's front-end edit release carries 93 dated rows out of 11,259, and one of them exists because the new gateway was caught rejecting claims it should have passed.
Subscribers - Aug 294 min read
The Oncology LCD Is on Version 220
CMS runs a free, key-free API across the whole Medicare Coverage Database, and it hands back every LCD's version number, revision history and diagnosis code tables as JSON. We pulled all 977 local coverage determinations through it this morning, and the median active policy is on version 22.
Free - Aug 287 min read
Medicare Set Its Screening Floor With a Test It Cannot Cover
NCD 210.3 now pays for any non-invasive colorectal biomarker test clearing one of two sensitivity and specificity pairs, and CMS showed its arithmetic. The lower bound is Freenome's SimpleScreen, which is not FDA market authorized. Coverage backdates to June 8; the edits go live January 4.
Subscribers - Aug 284 min read
How Long Has Medicare Had That Enrollment Application?
CMS publishes the list of initial enrollment applications its contractors have not processed, twice a week, by name. We pulled all 336 archived builds back to June 2023. The July wave drains every autumn like it should, and 1,116 physicians have been on every single build for 1,180 days.
Free - Aug 284 min read
How a Drug Price Drop Lands in Your Clotting Factor Fee
CMS set the 2027 clotting factor furnishing fee at $0.270 per unit yesterday, a 1.89% raise and the third-smallest in twenty-two updates. The fee pays for labor, and it is indexed to a basket where drug prices fell 2.1% this year. Twenty-two years of that blend put it 1.4 cents a unit behind, worth $3.3 million a year across Part B.
Subscribers - Aug 274 min read
The Grouper You Keep Rebuilding Already Exists
CMS quietly maintains a taxonomy that sorts all 17,174 Part B HCPCS codes into clinical service lines, re-argued every year by a panel of clinicians and researchers. The 2026 release posted August 21, it added exactly one new category, and 265 of the codes in it used to be DME.
Free - Aug 276 min read
Seven Devices Medicare Priced Off a Knee Replacement
CMS just posted the payment limitations for the last year of the NOPAIN separate payment, and seven of the twenty products carry the identical cap because the agency has never seen a claim for any of them. Comments close Monday.
Subscribers - Aug 275 min read
How a Code You Never Sent Ends Up on Your Claim
Seven days on the wire: CMS rewrote the list of codes it assigns to your claims for the first time since August 2024, adding 36 contractor bypass modifiers, deleting the incarcerated-beneficiary condition code, and repurposing a value code, all under a change request that says it contains no policy changes. Plus MolDX finalizes one batch and opens another, and CMS points dermatology at an audit it refused to concur with.
Subscribers - Aug 266 min read
Who Reads the CERT Letter at Your Practice?
On Friday CMS deletes the option that let your MAC sit on an unanswered CERT records request, and requires feedback to close at least 30 days before your last chance to send the chart. Unanswered requests already cost Medicare $3.46 billion last year, the only documentation category that rose while the overall improper payment rate fell, and for urological supplies they are 69.4 of the 74.1 percent error rate.
Subscribers - Aug 263 min read
How a Write-Off Turns Back Into a Patient Balance
CMS refreshed the Medicare enrollment file on Monday. Dual eligibles are now the smallest share of Medicare the agency has ever published, and 74% of the twelve-month decline sits in the one dual category that carries no federal bar on billing the patient for the coinsurance.
Free - Aug 264 min read
3,533 Referring NPIs Medicare Lists Both Ways
CMS publishes two files that answer the same question about whether a referral clears the 424.507 edit. On 3,533 opted-out practitioners the files answer it differently, all 3,533 are cleared for DMEPOS in one of them, and the remittance is where you find out which file your MAC read.
Subscribers - Aug 255 min read
Thirty-Nine New Lab Codes, and Not One Has a Price
Seven days on the wire: CMS quietly folded three recurring lab change requests into one, added 39 new laboratory codes effective October 1 with no national payment amount on any of them, deleted three others, and flipped a point-of-care respiratory assay to CLIA-waived retroactive to March. Plus a third state parity audit in eleven days, and an LCD feed that has not refreshed since August 17.
Subscribers - Aug 256 min read
The Sentence Labcorp Asked MolDX to Strike
On August 10 the four MolDX contractors turned on Medicare's first coverage policy for MASH fibrosis blood tests, naming five tests and conditioning every one of them on a FIB-4 result, an elastography lookback and a technical assessment. Seven weeks later Labcorp gets a national code for a sixth test that is on none of the four code lists, and the criterion standing in its way is the one Labcorp asked to have struck.
Subscribers - Aug 254 min read
Ask Your Payer What It Knows About Your Patients
On January 1 every Medicare Advantage organization, state Medicaid program and marketplace issuer has to run an API that hands your practice its record of your patients. The free specification that says how you ask was republished on August 22, and it changed because implementers pointed out that the first version would have shipped entire histories for thousands of attributed members in one request.
Free - Aug 244 min read
Medicare's DME Front Door Reopens Thursday
The nationwide moratorium on new medical supply company enrollments hits its six-month mark on August 27, and CMS has published no extension. The revocation file shows what the screens that come back are actually good at catching.
Free - Aug 246 min read
How the Venom Exception Fell Out of One MAC's Copy
Five Medicare contractors just published the same Allergy Diagnostic Testing LCD, word for word, across 38 states and $45.1 million of Part B testing. CGS's copy is missing two words, and the sentence they came out of is the one that decides whether a serum IgE test and a skin test can both be billed for the same antigen. CGS's own billing article still has them.
Subscribers - Aug 244 min read
How a Therapy Cleanup Stops Paying for Wound Care
CR 14561 calls it an administrative correction of therapy codes. It pulls 45 codes off the only list that makes them separately payable during a covered Part A SNF stay on October 1, and $10.6 million of the $11.2 million riding on those codes is wound care.
Subscribers - Aug 235 min read
Your Primary Payer Now Picks Your Medicare Denial
Seven days on the wire: CMS sorted 129 claim adjustment reason codes into four dispositions for every Medicare Secondary Payer claim at Part A, pulled 45 therapy codes off a skilled nursing facility list they should never have been on, terminated one code effective December 31, 2011, and told ambulatory surgical centers to bill a $261,579 gene therapy across ten claims. Plus a favorable OIG opinion on manufacturer-funded premium assistance.
Subscribers - Aug 234 min read
The Chest Brace That Talked CMS Into a New Code
CMS decided 49 HCPCS Level II applications out of the June public meeting and published every argument on both sides, including the one that moved a chest brace off a non-covered supply code and onto a new L code effective October 1. The record spells out the test. One applicant met it in writing, and another one did not.
Free - Aug 236 min read
Six Timepoints, Then Nothing After Year Five
On August 30 the MolDX allograft rejection LCD is replaced across four jurisdictions. Kidney surveillance went from four covered timepoints to six, the post-year-one allowance doubled, and the billing article quietly reports that no test on the market qualifies past five years.
Subscribers - Aug 227 min read
Your Obesity Code Decides Whether the Liver Test Gets Paid
MolDX switched on coverage for MASLD and MASH fibrosis biomarker testing across seven MAC jurisdictions on August 10, at lab fee schedule rates running from $176.19 to $792.17 for one test per patient per year. The claim needs a diagnosis from each of two lists, and the list that grew from 17 codes to 108 between draft and final still leaves out morbid obesity and metabolic syndrome.
Subscribers - Aug 224 min read
The $572 Million Code Medicare Never Priced
CPT 81479 carries no rate on the clinical laboratory fee schedule. Medicare paid $572.2 million on it in 2024, and the twelve labs that collected 94.6% of that averaged anywhere from $1,661 to $7,099 a test.
Subscribers - Aug 224 min read
How Much Warning Does an LCD Actually Give You?
CMS sets a 45-day floor on LCD notice and lets any MAC ask for more. Across 448 notice periods since the 2019 process reform, 355 ran exactly 45 days, and only ten cleared 52.
Free - Aug 216 min read
The Counter Does Not Care Who Drew the Blood
Five new UnitedHealthcare reimbursement policies take effect September 1 across commercial, the exchanges, and Medicare Advantage. They name 37 lab codes, stop paying 17 of them outright, and run every frequency counter at the member level, so the reference lab's claim spends the same allowance your office draw needs. Seven states are excepted, and they are the same seven that ran 62 to 121 days behind the first tranche.
Subscribers - Aug 214 min read
OIG Will Give You the Software It Extrapolates With
The audit OIG issued on August 3 found $8,112 in improper payments across 100 sacroiliac joint injection sessions and turned it into a $15.2 million finding. The program that does that arithmetic has been a free download on the OIG website since the late 1970s, and the Program Integrity Manual tells contractors to use it by name.
Free - Aug 215 min read
How the Eleventh Reason Code Gets Skipped
A transmittal CMS issued Wednesday says the Fiscal Intermediary Shared System has only ever handed the first ten medical policy reason codes on a Part A claim to the system that adjudicates them, and bypasses the rest. CMS concedes in writing that this lets some claims pay incorrectly. The fix was booked for the October release and just moved to January.
Subscribers - Aug 207 min read
What Nine Contracts Do to the CGM Channel
CMS published its Round 2028 bidder fact sheets this morning. Buried in the rule behind them is a worked example where one unchanged array of bids produces three different Medicare prices, and the only thing that moves is how many contracts CMS decides to hand out.
Subscribers - Aug 204 min read
CMS Wrote 3,646 Warnings to Reach 29 Fines
The Hospital Price Transparency enforcement file is now five and a half years long. Reading it case by case shows almost every warning ends in a Corrective Action Plan, not a check.
Subscribers - Aug 204 min read
$5.18 Million Got Its Own Compliance Tip
MLN Connects published a provider compliance tip this morning telling comprehensive outpatient rehabilitation facilities that their improper payment rate was 45.4 percent on $10.8 million. Both numbers come from the FY 2024 CERT report. The FY 2025 report has been out since November: 20.7 percent, $5.18 million, and the smallest line on the Part A ex-IPPS table.
Free - Aug 195 min read
The Rate Update That Shipped Without the Rates
CMS sent MACs the FY 2027 hospice payment instruction in July with the payment tables missing, and replaced it on August 18 to put them back. Two more transmittals were rewritten the same week under change request numbers that never changed, one of them quietly adding a place-of-service rejection edit to a CR whose summary still says no policy is being changed.
Subscribers - Aug 196 min read
The 16,488 Signatures Medicare Wants Before 2028
Section 6225 of the CAA, 2026 turns a separate NPI and a signed provider-based attestation into conditions of Medicare payment for every off-campus outpatient department on January 1, 2028. CMS had to count the departments to price the paperwork, and the number that fell out is the closest thing to a federal tally anybody has.
Subscribers - Aug 194 min read
How Six Vendor Names Change an Appeal Letter
The free appeal generator your patients use is an open repository, and its logic reads like a compliance document. It scans a denial for six utilization-management vendors, pulls NCD citations from the CMS Coverage API, retrieves prior external review decisions from California and New York, and refuses on purpose to say what any of it means.
Free - Aug 186 min read
Why the Same Square Centimeter Pays $109 in Arkansas
CMS announced one national skin substitute rate of $127.28 per square centimeter and then filed it as 3.81 practice expense RVUs. That makes it two rates before geography and 78 after it, running from $109.31 to $183.51 across the 109 Medicare localities. On a 100 square centimeter application the supply line is 98% of the allowed amount, and CMS has already written down the year that money starts moving everyone else's practice expense RVUs.
Subscribers - Aug 184 min read
The Hip Revision That Loses $13,047 on October 1
A two-page maintenance article pulled eight MS-DRGs off the list where device credits come out of your inpatient payment. They came off because CMS deleted them: hip and knee revision collapses from three severity levels to one weight, cardiac pacemaker work from five to two, and the complicated cases funded both.
Subscribers - Aug 184 min read
Medical Necessity Was Never the Question
OIG pulled 100 denial files at Oregon's largest Medicaid plan and 21 of them failed on process alone. It never sent a single request out for medical review, and the most common defect was that the wrong person made the call.
Free - Aug 177 min read
The $2,672 Observation Payment Now Turns on Six Edits
On October 1 UnitedHealthcare Medicare Advantage adds six claim-line denials to its observation policy, all of them gates around the same comprehensive payment. Medicare pays $2,672.15 for a properly formed observation stay and nothing for the observation code on its own, so each edit is a way to drop a four-figure claim to the price of the visit underneath it.
Subscribers - Aug 174 min read
Sage Transparency Already Has Your Hospital's Number
An employer coalition in Indiana commissioned RAND in 2016 to find out what private plans actually pay hospitals, and has been publishing the answer per facility, for free, ever since. The current edition prices 4,000-plus hospitals against Medicare across 49 states and DC. Enrollment for the next round, built on 2023 through 2025 claims, closes before November.
Free - Aug 175 min read
How a Rate Takes Effect Sixteen Days Before Your MAC Can Pay It
This season's influenza vaccine allowances carry an effective date of August 1 and an implementation date of today, so sixteen days of flu claims priced against last season. The Federal Register published nothing from CMS all weekend, and every change that actually reached a provider came from a contractor: a finalized allergy LCD in Jurisdiction E, a skin substitute billing rule First Coast wrote down 225 days after it started, and an OIG finding that three New York Medicaid plans are still out of parity six years past the deadline.
Subscribers - Aug 164 min read
Where Did the RAC Pipeline Go?
CMS runs two Recovery Audit topic lists: one for what the auditors are cleared to review, one for what they have proposed reviewing next. The proposed list returns "No data available", and the approved list has picked up eight new topic numbers since January 2024 while re-dating sixteen old ones.
Free - Aug 164 min read
CMS Capped the Cut and Published the Destination
A new step 19 in the CY2027 physician fee schedule holds every practice expense RVU to a 5% move per year, so the specialty impact table shows a fraction of what the new methodology does. CMS posted the uncapped file next to it. Priced on CMS's own utilization data, that file parks $3.23 billion of reallocation past 2027: ophthalmology down another 8.3% of its book, private-practice physical therapy up 15.9%.
Subscribers - Aug 166 min read
Cigna Posted 111 Changes and 55 Had Already Taken Effect
Cigna's August policy update went live on the 15th. Half its dated changes were already in force, including both reimbursement policies, and one of them keys your contrast payments to a Medicare indicator that splits the same tracer down the middle.
Subscribers - Aug 154 min read
The Prior Auth Registry Nobody Was Required to Build
CMS-0057-F made 1,378 health plans post their CY2025 prior authorization numbers on their own websites and created nowhere to put them. An independent site has collected 1,276 of those filings, plan by plan, with the source document behind every record. We tested its UnitedHealthcare entries against the filing we parsed ourselves last week.
Free - Aug 156 min read
Nine Overpriced Drug Codes, and CMS Won't Say Which
On August 10 the OIG told CMS that nine Part B drug codes are priced high enough to qualify for a payment cut, then sent the list over by secure file transfer. If one of them is on your buy-and-bill shelf, the payment limit drops at least 7.5% the quarter the substitution lands, and the only public warning is the file itself.
Subscribers - Aug 155 min read
How a Coverage Fix Becomes a Rejection Edit
CMS rescinded and replaced two quarterly NCD change requests on Thursday. One writes a return-as-unprocessable edit into the defibrillator NCD and backdates a place-of-service fix to October 2023, which is two years past the point where you can bill it. The other deletes an eleven-year retroactive payment instruction seven weeks before it was due to install.
Subscribers - Aug 146 min read
Who Decides How Often You Can Bill 77436?
Aetna's August bulletin caps the new superficial radiation planning code at one payment per course starting November 1. The device vendor's own coding desk has been telling practices to bill it every fraction, and Medicare's edits do not stop either reading. On a twenty-fraction course the answer is worth $1,491.
Subscribers - Aug 143 min read
51 Markets Hit the Wage Index Cap, and Everyone Paid
The FY 2027 SNF wage index falls more than 5% in 51 of 468 areas, so Medicare's permanent cap holds every facility in them at exactly a 5% drop. Statute makes that cap budget neutral, which means the rest of the country funds it, and the deferred cut comes back next October.
Free - Aug 134 min read
Who Grades Your Price File Before CMS Does?
CMS publishes the machine-readable file spec and the program that grades it in the same place, under a public domain dedication: npm install -g @cmsgov/hpt-validator-cli, point it at your own file, get the error list before a compliance reviewer does. Ten people have starred it.
Free - Aug 134 min read
Two Codes Carry 95% of Medicare's New Denials
CMS posted the CY2025 Physician/Supplier Procedure Summary on Tuesday. Medicare denied 15.68% of submitted Part B service units last year against 10.89% the year before, and two intermittent-catheter codes account for 94.9% of the increase. The specialty split says whose money it is.
Subscribers - Aug 135 min read
Medicare Will Not Call You About the Last APM Bonus
CMS published the 2026 APM incentive advisory Thursday: the final lump sum in the program's history, 1.88 percent of a qualifying clinician's 2025 professional charges, sitting undisbursed because the agency cannot match a tax ID to the clinician who earned it. Nothing gets mailed, nobody gets called, and on October 13 the claim is forfeited. Four other CMS clocks stop the same day, and the one that matters most closes sooner.
Subscribers - Aug 123 min read
Medicare Has Five Prices for an Hour of Your Time
Fifteen CMS rules published since April all price a manager hour off the same BLS occupation code, 11-9111. They land on five different numbers, from $96.36 to $135.54, and four of the five are exactly the four cells of a two-by-two: May 2024 or May 2025, mean or median.
Free - Aug 126 min read
How CMS Moved Your Recoupment Date Past the Interest Line
On January 4, recoupment on Part A cost report overpayments stops starting on day 16 and starts on day 41. Interest still starts on day 31, at 11.875%. CMS calls it burden relief, and the 25 extra days pay for themselves only if the cash earns 14.4 percent.
Subscribers - Aug 127 min read
280 Hours to Rebuild a Medicaid Benefit in Every State
CMS-2451-F ends federal matching for a defined category of Medicaid and CHIP services on October 13, publishes no code list, and scores the national implementation burden at 280 staff hours and $28,394. Three-quarters of the spending it reaches moves on outpatient pharmacy claims that carry no diagnosis.
Subscribers - Aug 113 min read
The Reassignment Map Medicare Gives Away
CMS publishes the full reassignment graph of Part B once a month, free and without an account: 3,373,759 rows tying 1,692,686 practitioners to 205,490 billing groups, with both revalidation clocks printed next to each other. Half of those groups have exactly one person in them.
Free - Aug 115 min read
How a Maintenance Update Reopens Three Years of Claims
CMS issued two NCD coding change requests on August 7, both stamped effective January 1, 2027. Not one of the fourteen edits inside them takes effect on that date, one reaches back to October 2023, and the two halves give your MAC different orders on whether to fix the claims it already denied.
Subscribers - Aug 113 min read
Home Health's $4.9 Billion Still Has No Due Date
CMS told home health agencies last December it would consider a schedule for collecting the PDGM balance. The CY 2027 proposed rule prices that balance at $4,908,531,936, proposes a second straight year of 3 percent, and says it is not establishing a timeframe. Comments close August 31.
Subscribers - Aug 105 min read
Who Is Paying for the Dialysis Raise?
CMS proposes a $17.84 increase to the ESRD base rate for CY2027. Phosphate binders account for $16.06 of it, and a rebuilt low-volume adjustment charges every facility above 8,000 treatments $3.34 a treatment to fund the ones below. Comments close August 24.
Subscribers - Aug 103 min read
The Contracts That Ask the Most Say No the Least
UnitedHealthcare's first filing under the CMS prior authorization transparency rule covers 8.6 million requests across 63 Medicare Advantage contracts. The blended denial rate is 12.9%. The contract-level rate runs from 1.9% to 23%, and the spread has a mechanism behind it.
Free - Aug 106 min read
Medicare Priced Your Prior Auth at $22.14
CMS wants prior authorization on eight more botulinum toxin codes starting July 1, 2027, and the proposed rule prints its own cost model. Here are the codes, the arithmetic, and the lines the model leaves out.
Subscribers - Aug 94 min read
The Rate Sheet Your Competitor Already Published
Trilliant Health consolidated every hospital machine-readable file it could parse into one free DuckDB lake: 7,698,910,156 negotiated rates this morning, no license and no sales call. Nine of every ten files are on the CMS 3.0 template, which is the version that carries real remittance-derived allowed amounts.
Free - Aug 93 min read
The 24 Percent Margin Medicare Just Gave a Raise
MedPAC voted 17-0 in March to cut base rates for skilled nursing, rehab and hospice. Every one of those settings got 2.3 or 2.4 percent in the FY 2027 final rules that finished landing Tuesday. We price the distance between the votes and the rules at about $4.3 billion for one fiscal year, and show where it sits.
Subscribers - Aug 95 min read
Device Makers Move to the Front of the Coverage Line
CMS filed a new device coverage pathway at 4:15 on Friday afternoon: a proposed national coverage determination the same day FDA authorizes the device, and the two-year-old TCET pathway closed to new candidates. In the same week, its own auditor asked for a national policy on sacroiliac joint injections and CMS said no.
Subscribers - Aug 83 min read
Who Ordered the Catheters?
Urological supplies just became the largest improper payment line in DMEPOS: 74.1% and $885.8 million, more than triple the year before. CMS's own table says the rate turns almost entirely on who is listed as the referring provider, and the compliance page a supplier would go read still quotes last year's number.
Free - Aug 86 min read
How Three Sessions a Quarter Became Three a Year
Novitas and First Coast rewrote their trigger point injection LCDs with identical text, effective September 6. The session count in the policy is unchanged. The window it sits in went from three months to twelve, and four other things stopped being covered on the way.
Subscribers - Aug 85 min read
Anthem Brings the ED Leveler to Ohio Medicaid
Policy G-19002 has run on Anthem's Medicare Advantage book since 2019 with four printed exclusions. The Ohio Medicaid version lands November 1 and prints none of them, and the prudent layperson rule everyone reaches for does not reach a downcode.
Subscribers - Aug 75 min read
Four Error Rates Went Up, and So Did Every Target
HHS's own auditor says Medicare Advantage's improper payment rate rose to 6.09 percent and the RADV audits meant to claw it back have returned nothing yet. Plus two home health survey tags that took effect the day they were written, and the change request that puts Medicare's prior authorization denial reason into the beneficiary APIs.
Subscribers - Aug 74 min read
CMS Just Published Everyone's ABA Rates
The new state toolkit for applied behavior analysis runs 173 pages, and the last appendix is the part to keep: reported 2025 Medicaid fee-for-service rates by state and CPT code, verified against paid claims. The assessment code spans six to one.
Free - Aug 74 min read
8% of Practitioners, 18% of the RVUs
CMS quietly published a spreadsheet showing how the CY 2027 fee schedule lands on individual practitioners rather than on specialty averages. Count practitioners and 8.3% take a cut deeper than 2%. Count RVUs and it is 17.6%, roughly $15 billion of the fee schedule. The specialty average everyone quotes is published as five TIFF images.
Subscribers - Aug 67 min read
What Happens When the Speech Eval Slips Past Noon?
CMS made one word plural in the IRF basis-of-payment regulation and turned a therapy-scheduling detail into a condition of coverage for the entire stay. Two clocks, both effective October 1, both counting from different moments. The only dollar figure the agency ever attached to the package is $399.06 a week.
Subscribers - Aug 66 min read
How One Nursing Home Visit Got Two Medicare Rates
The CY 2026 facility practice expense cut split nine nursing facility E/M codes by the beneficiary's Part A status, so the same visit pays two rates depending on who is covering the bed. We priced the gap at $423 million on CMS's own utilization weights. The CY 2027 proposal closes it for these nine codes and asks, in the same section, whether facility practice expense should go to zero for everyone else.
Subscribers - Aug 64 min read
For the Median Nursing Home, the Quality Bonus Is a 1.4% Cut
FY 2027 SNF VBP score reports hit iQIES this week and the program now runs on eight measures instead of four. The FY 2026 results are public, and they show what the machinery actually pays: 78.6% of 13,900 SNFs got back less than Medicare withheld, and the median multiplier was 0.9864. Corrections close August 30.
Free - Aug 54 min read
What Does the Federal Record Say About Your Doctors?
CMS is running an open FHIR API over the national provider directory at directory.cms.gov, with 35.7 million rows and no login. Fifty-nine percent of it is the affiliation table, every practitioner record carries an HHS exclusion-list flag, and the Medicare Advantage plans feeding it now owe CMS a 30-day refresh clock and an annual accuracy attestation.
Free - Aug 55 min read
The Week CMS Put a Clock on Its Own Contractors
A rewritten provider-audit manual gives MACs 90 days to answer a reopening request and 18 months to settle an unaudited cost report, the first published deadlines that run against the contractor rather than you. Plus a Medicaid ABA toolkit that prices four years of growth at 421 percent and hands states the billing patterns to go looking for.
Subscribers - Aug 54 min read
One in Nine IRFs Would Have Missed the New Deadline
CMS just cut the post-acute quality reporting window from four and a half months to 45 days, in three final rules over five days, and wrote that it creates no additional burden. Its own compliance analysis inside those rules says 11.5 percent of IRFs and 5 percent of SNFs would not have made it. We price what a miss costs: about $388 a discharge.
Subscribers - Aug 46 min read
Medicare Might Not Take the New OB Codes at All
CMS overruled the RUC and added 15 percent to every labor and delivery code, then asked whether it should skip the CPT 2027 maternity restructure entirely and mint fifteen G-codes that keep the global package alive. Comments close September 14.
Subscribers - Aug 44 min read
Medicare Added $39 to the High-Dose Flu Shot
The 2026-2027 Part B vaccine allowances took effect Saturday. Fluzone High-Dose, Flublok and Fluad all went from $83.49 to $122.52 across two seasons, while the manufacturers' own reported contract price sat still at $86.23. Standard dose moved by cents, and all six COVID-19 codes are still blank.
Free - Aug 46 min read
How an MA Readmission Lands on Your Fee-for-Service Check
On October 1, Medicare Advantage patients enter all six readmission measures and the applicable period drops from three years to two. The dollars the penalty gets applied to stay fee-for-service. We price the asymmetry, take apart the new sepsis measure, and map the rest of the measure stack running the same change.
Subscribers - Aug 34 min read
What Happens to the Hospice Cap Money Nobody Collects?
The FY 2027 hospice aggregate cap published this morning at $36,174.75, $35.36 below what CMS proposed in April. MedPAC now puts 28% of hospices over the cap, about $750 million a year in overpayments, and OIG audits of the three MACs that collect it found between 4% and 27% of the money written off as uncollectible.
Subscribers - Aug 35 min read
The Reminder Buried in UnitedHealthcare's August Bulletin
Seven days across the payer bulletins and the CMS manual system: 93 revenue codes become conditional on October 1, the AMA retires the global obstetric package, and nine UnitedHealthcare spine and joint policies land on a single September date. Every change, its effective date, and who it hits.
Subscribers - Aug 34 min read
How a Once-in-a-Lifetime Test Got Billed 520 Times
CMS put its analytics, OIG's exclusion authority and state payment suspensions in the same room in April. Eighty-eight days later it published the scoreboard: 50 providers, $203.3 million, and one lab that billed a once-in-a-lifetime gene test over and over on the same 520 people.
Free - Aug 24 min read
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.
Free - 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.