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Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
Medicare Open Enrollment Starts October 15: What Plan Exits Mean for Practices
Medicare open enrollment runs October 15 to December 7, 2026, and at least 33 health systems have left or are leaving Medicare Advantage networks while insurers trim their 2027 footprints. Here is what practices should expect in January and what to set up now at the front desk.
Prior Authorization for Drugs: Pharmacy vs Medical Benefit and Step Therapy
A drug denied at the pharmacy counter and a drug denied before an infusion are two different problems with two different rulebooks. Here is how prior authorization for drugs works under the pharmacy benefit and the medical benefit, what step therapy requires, the Medicare clocks, and the fastest route to an approval.
Medicare Advantage Non-Contracted Providers: Payment, Appeals and the Waiver
A practice that treats a Medicare Advantage patient without a contract is not out of luck. Federal rules set what the plan must pay, how fast, and how to appeal a denial. Here is how the payment floor works, why the waiver of liability form matters, and the mistakes that turn a payable claim into a write-off.
Payer Policy Monitoring: A Monthly Routine for Bulletins and Scrubber Rules
Payers change reimbursement policies every month and tell you in bulletins nobody reads. We describe a two-hour monthly routine: which sources to check and when, how to triage what applies to you, the change log fields that matter, and how to turn a policy notice into a scrubber rule before the effective date.
UnitedHealthcare September 1, 2026 Lab Policies: Testosterone, B12, Allergens
UnitedHealthcare's August 2026 bulletin restates five routine test management policies for Medicare Advantage that take effect September 1, 2026, covering testosterone, vitamin B12, allergen testing and more. Here is what each one limits, which practices will see denials, and how to get orders ready.
Five Months to the January 1, 2027 Prior Authorization API Deadline
On January 1, 2027, Medicare Advantage, Medicaid managed care and Marketplace plans must offer a FHIR prior authorization API under CMS-0057-F, and the insurers' 2025 pledge to standardize electronic prior authorization comes due. What will change, what will not, and the five questions to ask your EHR vendor now.
How to Bill Newborn Claims: The 30-Day Enrollment Window and Month-Two Denials
Newborn claims pay in month one and deny in month two because nobody added the baby to the plan. We walk through the three coverage clocks that start at delivery, how to bill under the mother's ID, the CARC codes that follow, and the front desk script that stops the problem.
Workers' Compensation Billing for Practices: Authorization, Fee Schedules, Forms
Workers' compensation claims follow state rules, not payer contracts, and most billing teams learn them by losing money. We cover what to capture before the first visit, how state fee schedules and filing limits work, the reports that must ride with every bill, and the denials that follow when they do not.
UnitedHealthcare July 2026 Policy Updates: What Your Practice Should Check
UnitedHealthcare posted its July 2026 monthly overview and policy bulletins on July 1. Most items are quarterly code housekeeping, but a DME process change in eleven states, three prior authorization changes with fall dates and several state Medicaid items deserve a look now.
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