Weekly roundup
Here’s what you missed last week!
🏛️ Policy & Payers
Expect tighter coding controls as BCBS Massachusetts expands post-pay reviews targeting potential overcoding among 1–4% of physicians, raising audit and recoupment risk; see the expanded claims reviews.
Plan for access friction as new FDA-approved therapies can face coverage delays up to 1 year, with many plans lacking policies post-approval; note the reported coverage delays up to 1 year.
Prep for cleaner data exchange as Providence and Humana pilot FHIR APIs to standardize payer-provider sharing, which could cut denials from bad data; follow the FHIR APIs.
Resume normal billing on affected services since CMS lifted the shutdown-related telehealth claims hold.
Push payers on step therapy as Congress reintroduced the Safe Step Act, seeking guardrails that could speed access for chronic derm conditions.
📈 Business & Tech
Expect faster payer responses as Optum unveiled an AI-powered claims processing platform to boost throughput and accuracy.
Watch for clearer eligibility at check-in as Optum rolled out real-time patient health benefit information to surface coverage details during visits.
Plan for more automation pressure as Elevance ramped AI investments to streamline operations and service.
Trim documentation time where available as Abridge reported gains from ambient AI documentation across large systems.
⭐ Just for Fun
The Deep Dive
Medicare Telehealth Just Ended. Now What?
Why it matters. In dermatology, complex compensation is the norm. We use productivity bonuses, wRVU-based formulas, and ancillary service commissions to recruit and retain top talent. But these complex plans, if structured or paid incorrectly, are a primary source of financial risk. A misaligned plan can trigger DOL audits, provider disputes, and staff turnover... turning your top performers into your biggest liabilities.
Provider Salary vs. Draw
The most common compliance trap for practice owners is mismanaging the "salaried-exempt" status for providers on productivity. Many practices pay a "draw" against future collections. This is fine, but it cannot violate the Fair Labor Standards Act (FLSA).
The FLSA "safe harbor" requires that an exempt, salaried employee receive their full, guaranteed salary for any week in which they perform any work. You cannot reduce this salary, even if their productivity for that pay period is zero.
DON'T: Treat a provider's draw as a simple variable wage that can be reduced in a slow month.
DO: Structure the plan with a guaranteed base salary that meets the FLSA threshold (and any state-level minimums).
DO: Define productivity bonuses as additional compensation, paid out at a clear reconciliation period (e.g., quarterly) after collections have exceeded the threshold covered by their base salary. This keeps you compliant while still incentivizing performance.
Auditing Your "Ancillary" Payouts for Staff
Your providers aren't the only ones on incentive plans. Many practices offer bonuses to MAs or estheticians for cosmetic procedure "assists" or product sales. This is where a second, more insidious FLSA rule comes into play: the "regular rate of pay."
For your non-exempt (hourly) staff, you must include all non-discretionary bonuses and commissions when calculating their overtime rate.
Here’s the simple math that trips up practices:
An MA earns
$25/hour. She works45hours one week.She also earns a
$100bonus for product sales that week.Incorrect OT Calculation:
5hours @$37.50(1.5x$25) =$187.50in OT pay.Correct OT Calculation:
Total Straight Time Pay: (
45hours x$25) +$100bonus =$1,225"Regular Rate":
$1,225/45hours =$27.22/hourOT Premium Owed:
$27.22x0.5(the "half") =$13.61per OT hourTotal OT Pay: (
5hours x$13.61) =$68.05Total Pay:
$1,225(straight time + bonus) +$68.05(OT premium) =$1,293.05
That $18.75 error ($68.05 vs. $50), multiplied across all staff and all pay periods for three years, is exactly what a DOL auditor looks for.
What Your Contract and Payroll Process Must Align On
Your employment agreement is your primary compliance document. Your payroll administrator must be able to execute exactly what the contract states.
Conduct an audit to ensure every provider contract clearly defines:
The Compensation Base: Is it a guaranteed salary or a recoverable draw (and how is it recovered)?
The Productivity Formula: Is it based on net collections, gross charges, or wRVUs? Be precise.
Service & Payer Carve-Outs: Are cosmetic services paid at a different rate than medical E/M codes (e.g., 99204, 99214)? How are path codes (e.g., 88305) or Mohs stages handled? Are some low-reimbursement payers excluded from the bonus calculation? (For more on CPT codes, see the AMA's official guidance.)
Reconciliation Timing: When is productivity "trued-up"? Monthly, quarterly, or annually? This has major cash flow and compliance implications.
Bottom line: Your provider compensation plan is a core financial document; treat it with the same audit-level scrutiny as your RCM to protect your practice from costly legal and financial exposure.
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.
