Five months of 2025 claims are now adjudicated, which makes June the first month where a practice can see whether the changes that took effect on January 1 were handled correctly. In our experience they usually were not, entirely. The fee schedule was loaded but one payer's escalator was missed. The new codes were in the system but nobody billed them. The telehealth rules were extended but the modifier logic was not updated. Each of these is small, and each has been leaking for five months.
This is not a general leakage review; we have written about the six standing categories elsewhere. This is a specific check on the things that changed in January 2025, done once, in June, while there is still time to correct the second half of the year and rebill what timely filing allows.
Key takeaways
- The 2025 Medicare conversion factor fell to $32.3465 from $33.2875; every contract pegged to the current-year Medicare schedule moved with it and every contract pegged to a fixed year did not. Check which is which.
- New 2025 codes, including the advanced primary care management codes G0556 to G0558, are leakage of a particular kind if the practice does the work and has never billed them.
- Medicare telehealth flexibilities did not expire on December 31, 2024; they were extended to March 31 and then to September 30, 2025. Workflows changed for an expiry that never happened should be reversed.
- Missed contract escalators are the most common finding in the contract section of our audits, and they are invisible if the expected-payment table was never updated either.
- Six reports, one afternoon, and a written reprocessing request to every payer with a variance.
Check 1: the 2025 conversion factor and your contracted rates
The 2025 Medicare Physician Fee Schedule conversion factor is $32.3465, down about 2.83% from $33.2875 in 2024, after Congress did not extend the previous year's temporary adjustment. Every contract that pays a percentage of the current Medicare fee schedule moved with it, and every contract tied to a fixed year (for example, "110% of the 2023 Medicare fee schedule") did not. The leak runs in both directions: a payer applying the 2025 cut to a contract pegged to 2023 rates is underpaying, and a practice that loaded the 2025 schedule into its expected-payment table for a contract pegged to 2023 will never see the variance.
The report: paid amount versus expected contracted amount by payer and CPT, for January through May, for your top ten codes. Any payer where the variance is consistent across codes has a fee schedule loaded wrong on one side or the other.
A worked example. A commercial contract pays 115% of the 2023 Medicare fee schedule. The 2023 national rate for 99214 was about $126, so the contracted rate is about $145. In January the payer starts paying $141, which is 115% of the 2025 rate. Four dollars a visit on 600 visits a month is $2,400 a month, and by June it is $12,000 the payer owes under the contract. Nobody noticed because the practice's expected-payment table was updated to the 2025 schedule at the same time, so the variance report showed zero.
Check 2: new codes you are entitled to bill and have not
January 2025 introduced advanced primary care management codes G0556, G0557 and G0558, monthly codes that bundle care management services by patient complexity without the minute-counting of chronic care management. It also brought caregiver training codes and changes to several telehealth and behavioral health codes. If your practice does the work these codes describe and has not billed them once in five months, that is leakage of a particular kind: revenue never asked for.
The report: a frequency count of every code billed in 2025 compared with the list of codes new for 2025 in your specialty. Zero occurrences of a code your practice qualifies for is a conversation with the providers, not a billing fix.
Check 3: telehealth extensions and modifier logic
The Medicare telehealth flexibilities that were due to expire on December 31, 2024 were extended twice: to March 31, 2025 by the December 2024 continuing resolution, and then to September 30, 2025 by the full-year appropriations act signed on March 15. Practices that changed their telehealth workflows in anticipation of the December expiry, or stopped offering audio-only visits, or moved patients to in-person visits they did not need, gave up revenue they were entitled to. Others kept billing correctly through March and then applied an expiry that never happened.
The report: telehealth claims (place of service 02 and 10, modifier 95 and 93) by month for October 2024 through May 2025, with denial rates. A drop in volume in January or April, or a spike in denials for place of service, points to a workflow change that should be reversed before September 30, when the current extension ends.
Check 4: contract escalators that did not escalate
Many commercial contracts include an annual rate increase effective January 1 or on the contract anniversary. Payers load these late or not at all, and the practice's expected-payment table often still shows last year's rate, so the underpayment is invisible. This is the single most common finding in the contract section of our audits.
The report: the contract file, opened to the rate section, for every payer with an escalator, compared with the actual paid amounts for a 99213 and a 99214 in January and in May. If the paid amount did not change on the escalator date, the payer has not loaded it and every claim since is underpaid.
Check 5: deductible-season balances that never reached the patient
January through March is when most commercial deductibles reset, and a large share of the allowed amount on early-year claims becomes patient responsibility. Those balances have now had time to be statemented, paid, or ignored. Practices with monthly statement cycles and no follow-up after the third statement have a pool of first-quarter patient balances that will quietly become bad debt by autumn.
The report: patient balances by date of service for January through March, with last statement date and last payment date. Balances with no statement in the last 45 days, or three statements and no payment, need a decision: a call, a payment plan offer, or a collections referral.
Check 6: revalidations and reattestations that came due
Medicare revalidation notices, CAQH reattestation every 120 days, and commercial recredentialing cycles do not care about the calendar year, but a mid-year check is a good time to look ahead. A revalidation missed in June stops Medicare payment for a provider in July or August, and the claims that pile up in the meantime are not always recoverable.
The report: every provider's Medicare revalidation due date (from the PECOS revalidation lookup), CAQH attestation date and each payer's recredentialing date, listed with anything due before December 31 highlighted.
Putting a number on it
| Check | How to size the finding | Recoverable? |
|---|---|---|
| Fee schedule variance | Average variance per line multiplied by lines paid since January 1 | Usually, by reprocessing request or appeal within the payer's window |
| Unbilled new codes | Eligible patients multiplied by the monthly rate and by months | Rarely for past months; fully going forward |
| Telehealth workflow errors | Denied or unbilled telehealth visits multiplied by average allowed | Denials yes, if within timely filing; visits not offered, no |
| Missed escalators | Rate difference multiplied by volume since escalator date | Usually, with a written request citing the contract |
| Unworked patient balances | Sum of balances with no activity in 45 days | Partially, depending on age and follow-up |
| Revalidation gaps | Provider's monthly Medicare collections multiplied by months at risk | Avoidable if caught now |
Sizing matters because it sets the order of work. In a typical primary care practice the fee schedule and escalator findings are the largest in dollars and the most recoverable, so they go first and they go to the payer in writing this month. The unbilled codes are the largest going forward but need provider agreement, so they go to the next provider meeting. The patient balances are the most labor for the least return per account, so they get a rule (three statements, then a call, then a decision) rather than individual attention.
The Revelrex RCM audit covers these checks alongside the standing leakage categories, and practices on Revelrex billing receive the fee schedule variance and escalator reports as part of the monthly review.
Questions we hear
Why June and not January?
Because in January nothing has adjudicated yet. You cannot see a fee schedule variance until claims are paid, and you cannot see a workflow error until the denials arrive. Five months of data is enough to see a pattern and early enough to fix the year.
Our billing company says they check all of this. Should we still run it?
Ask them for the reports. A billing company that checks fee schedule variance can show you the variance report; one that says it checks but cannot produce the report is telling you something.
We found a payer underpaying since January. How far back can we go?
It depends on the payer's contract and state law. Many contracts allow corrected payment requests within 90 to 180 days of the remittance, and some state prompt-pay laws give longer. Start with the most recent claims and work backwards while you check the contract terms.
What to do this month
- Run the six reports above for January through May. One afternoon for a practice manager with report access.
- For every payer with a fee schedule variance or a missed escalator, send a written reprocessing request this month. Payer windows for corrected payment requests are often 90 to 180 days.
- Take the new-code list to the next provider meeting with the count of zero occurrences.
- Reverse any telehealth workflow change made for an expiry that did not happen, and calendar September 30 for the next decision point.
- Work the first-quarter patient balance list to a decision on every account.
- Put every revalidation and recredentialing date due this year on one calendar with a 60-day warning.
