Practical knowledge from people who do the work.
Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
The AMA's New Prior Authorization Survey and the CMS-0057-F Clock
The AMA released its 2024 prior authorization physician survey on February 24, 2025: 93 percent of physicians report care delays and 29 percent report serious adverse events. Federal payer deadlines under CMS-0057-F start January 1, 2026. Here is what to build now.
Documenting Medical Necessity for Imaging Orders So the Claim Survives Review
Advanced imaging is denied for missing necessity more often than for missing authorization, and the order is usually where it fails. Here is what a reviewer looks for in the note, the ICD-10-CM specificity that matters, a before-and-after note, and a table of the elements by study type.
UnitedHealthcare's February 1 Edits and Other Early-2025 Payer Changes
UnitedHealthcare's January 2025 bulletin brought new shoulder arthroscopy edits, radiation therapy unit limits and a code retirement for April 1. Here is what changed, who it affects, and the monthly routine we use to keep payer policy changes from turning into denials.
Credentialing a Provider Who Starts in Q1: A Plan When You Are Already Late
A physician starts April 1 and the enrollment file was opened last week. It happens every winter. Here is how we triage the payer list, what Medicare allows retroactively, how to schedule around pending plans, and the claim-holding discipline that keeps timely filing intact.
Change Healthcare Breach Now 190 Million People: What Practices Do Next
UnitedHealth Group told regulators on January 24, 2025 that the February 2024 Change Healthcare attack affected about 190 million people, up from 100 million. Here is what that means for a practice's own obligations, its vendor list, the 2024 claims backlog and its clearinghouse contingency plan.
OCR's Proposed HIPAA Security Rule: What Small Practices Should Know and Do
HHS published a proposed rewrite of the HIPAA Security Rule on January 6, 2025, with comments due March 7. Mandatory multifactor authentication, required encryption, a documented asset inventory and a 72-hour restore target are on the list. Here is what it means for an independent practice.
Deductible Reset Scripts: What the Front Desk Should Say in January 2025
Every January the deductible resets, half the patients have a new card, and the front desk absorbs the frustration. Here are the scripts we give registration staff, the card fields to check, the eligibility steps that prevent February denials, and a table of scenarios.
The 2025 Medicare Fee Schedule Is in Effect: What Changes on Your January Claims
The conversion factor dropped to $32.35 on January 1, 2025, G2211 can now be paid with modifier 25 in some visits, and Medicare will not pay most of the new telemedicine CPT codes. Here is what to change in the billing system this month and what to watch.
Telehealth Extended to March 31 and a Proposed HIPAA Security Rule Overhaul
Congress extended Medicare telehealth flexibilities through March 31, 2025 in the December 21 funding law, three months instead of the two years an earlier draft promised. Six days later OCR proposed the first major HIPAA Security Rule update since 2013. Here is what each means for the first quarter.
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