Weekly roundup
Here’s what you missed last week!
🏛️ Policy & Payers
Federal investigators are now flagging add-only retrospective coding programs as evidence of fraudulent intent in Medicare Advantage audits, a shift that puts any plan relying on one-way retro adjustments squarely in the crosshairs of DOJ enforcement.
Sidecar Health launched upfront guaranteed pricing for nearly all physician visits, letting patients see exact out-of-pocket costs before they walk in the door and bypassing the traditional claims adjudication process entirely.
UnitedHealthcare, Anthem, and Cigna are tightening E/M billing oversight with new policies targeting modifier 25 usage, systematic downcoding, and peer-to-peer claim comparisons; we broke down the appeal playbook in our downcoding deep dive last year.
3 of 4 Regence plans posted operating losses in 2025 as medical claims costs surged past premium revenue, adding to the growing list of regional Blues plans bleeding cash.
Managed Medicaid MCOs reported $2.8 billion in combined losses as enrollment declines from redeterminations collided with higher acuity among remaining members, turning what was once a reliable profit center into a drag on payer balance sheets.
New PBM reform legislation eliminates rebate incentives tied to list prices, shifting the pricing pressure from pharmacy benefit managers onto drugmakers who have historically relied on inflated sticker prices to fund the spread.
HHS began enforcing information blocking penalties against health IT developers and providers who restrict electronic patient data access, marking the first real consequences since the rule took effect in 2021.
📈 Business & Tech
AWS rolled out an agentic AI solution targeting scheduling, ambient documentation, and medical coding, positioning Amazon as a direct competitor to standalone healthcare AI vendors.
Procode AI acquired a surgical billing firm and launched AI-powered RCM workflows backed by fresh funding, combining specialty coding expertise with automated charge capture and denial management.
Tennr raised capital to automate patient referral workflows, replacing the phone calls, faxes, and manual documentation that bog down intake at high-volume practices.
Hospitals investing in dedicated tech staffing roles are reporting measurable gains in both care delivery speed and revenue cycle performance, as organizations that treated IT hiring as optional now face compounding operational gaps.
Google Cloud partnered with CVS, Humana, Waystar, and Quest Diagnostics to deploy AI tools across claims processing, lab diagnostics, and member engagement.
Health systems using AI for administrative cost reduction are reporting early savings in billing, scheduling, and prior authorization workflows, though most programs remain in pilot stages.
Healthcare AI startups that can't demonstrate clear ROI within 12 months are struggling to close contracts as health system procurement teams shift from "innovation interest" to hard financial benchmarks.
🩺 Clinical
Device-based acne treatments are gaining traction as clinicians report improved outcomes and higher patient satisfaction when pairing energy devices with standard topical and oral therapies.
A new study found that sunscreen SPF protection does not correlate with price, with budget and premium products performing comparably in controlled UV exposure testing.
AI-powered systems are showing early results in managing patient follow-up workflows, aggregating data from visits, labs, and imaging to flag overdue actions that would otherwise slip through the cracks.
The Deep Dive
5 MACs just rewrote the rules on SRT for dermatology
Five Medicare Administrative Contractors dropped coordinated Local Coverage Determinations on March 1, restricting superficial radiation therapy for skin cancer. The panic in derm circles is that MACs just banned SRT for dermatologists. That's not what happened.
What actually changed
On March 1, 2026, Noridian, WPS, Palmetto GBA, CGS, and NGS all went live with SRT-specific LCDs covering roughly 35 states. This is the first time multiple MACs have coordinated coverage restrictions for SRT simultaneously.
The biggest change: SRT is no longer first-line. Patients who can get Mohs or excision must get Mohs or excision. SRT is covered only for non-surgical candidates in these jurisdictions.
The provision that hits hardest is the IGSRT exclusion. Image-guided SRT and electronic brachytherapy are out. Daily ultrasound guidance with superficial treatments is now deemed "not reasonable and necessary." That's a direct shot at the turnkey SRT model that's spread across 500+ physician offices.
Then there's the training documentation requirement. Providers must document radiation training from "an accredited residency and/or fellowship program" in radiation oncology or from a "qualified dermatology program of training with didactic and clinical experience in radiation treatment." Read that again. Dermatologists are not excluded. The LCD requires documented training, not a specific board certification in radiation oncology. ASTRO pushed for that exclusion and didn't get it.
Who's affected right now
Here's where each LCD applies:
MAC | LCD | States |
|---|---|---|
Noridian | AK, AZ, CA, HI, ID, MT, ND, NV, OR, SD, UT, WA, WY | |
WPS | IA, IN, KS, MI, MO, NE | |
Palmetto GBA | AL, GA, NC, SC, TN, VA, WV | |
CGS | L40179 | KY, OH |
NGS | CT, IL, MA, ME, MN, NH, NY, RI, VT, WI |
Novitas and First Coast have not issued SRT LCDs. That leaves TX, FL, PA, NJ, CO, AR, LA, MS, NM, OK, DE, DC, and MD without restrictions. For now.
The reimbursement shift underneath
While the LCDs grabbed attention, CMS also restructured how SRT gets billed. Old codes 77401 and G6001 were deleted January 1, 2026. New SRT-specific codes replaced them as part of the broader 2026 coding updates:
77436 (treatment planning) and 77437 (delivery) are both billable per lesion per fraction, and 77437 requires the KX modifier to confirm medical necessity.
77437 carries a 300%+ reimbursement increase over the old delivery codes, per Sensus Healthcare and EZDerm's coding analysis.
77439 (ultrasound guidance) exists on paper but is non-covered under the new LCDs. Dead on arrival in 35 states.
Billing teams are reporting MUE limits of 1 per day for 77436 and 77437 starting April 1. CMS released the MUE updates for Q2 on March 1. If those limits stick, practices treating multiple lesions per visit will need to schedule them across separate days.
The politics behind the policy
This isn't just a billing story. It's a turf war.
ASTRO has pushed for years to restrict SRT to board-certified radiation oncologists. DART fired back, mobilizing 250,000+ public comments against the proposed LCDs and arguing IGSRT delivers cure rates above 99%. A meta-analysis of 18,056 NMSC cases tells a different story: SRT recurrence at 6.3% vs. 1.9% for Mohs.
The IGSRT exclusion hits SkinCure Oncology directly. They've built a turnkey model placing SRT equipment in 500+ physician offices at zero upfront cost. Image guidance was central to their clinical pitch. With HRUS non-covered, the economics of that model change.
The MACs landed in the middle: qualified dermatologists can still perform SRT. They just need to prove their training and document everything.
Takeaways
Check your MAC and verify your training documentation. If you're in one of the 35 affected states, confirm your providers have documented radiation training from a qualifying program. This parallels what we've seen with credentialing gaps that cost practices six figures. Add a statement to each treatment record confirming the provider meets the LCD's training requirements. Don't wait for a records request.
Audit your SRT patient selection criteria today. Every SRT patient needs documented medical necessity explaining why surgery is not an option. If your charts say "patient prefers radiation," that won't hold up - they should sign an ABN indicating they are aware this isn't covered under the policy. Medical contraindication, age, frailty, or specific clinical factors must be in the note.
Rethink your IGSRT workflow before your next treatment cycle. If your practice uses ultrasound-guided SRT, 77439 is non-covered in LCD states. Evaluate whether standard SRT protocols meet your clinical needs. Practices relying on the SkinCure IGSRT model need to have that conversation now, not after claims start denying. And know your payer contracts. Commercial payers aren't bound by these LCDs, but they watch MAC decisions closely. Medicare Advantage plans will follow these LCD guidelines.
Bottom line: Novitas and First Coast haven't moved yet. But 5 MACs acting together on March 1 isn't a coincidence. It's a signal. The practices that tighten their documentation and patient selection now will be ready when the remaining MACs decide.
Need a pro?
When you're ready for an expert to make your practice's billing bulletproof, schedule a strategy call with our team.
That’s it for this week.
This one was super fun. Hope you enjoyed it too.
