Weekly roundup
Here’s what you missed last week!
🏛️ Policy & Payers
Plan for financial adjustments: significant changes to Medicare Part B payment policies will affect operations starting in 2026.
Prepare for system updates as the CPT® 2026 update brings 418 total changes, including 288 new codes.
Update your compliance documentation because CMS released the HCPCS Level II codes update for 2026, critical for billing supplies.
Reduce prior authorization hassle: Aetna is merging prescriptions and procedures into a single prior authorization review to simplify patient access.
📈 Business & Tech
Watch for new employer competitors since Angle Health secured $134 million for cost-saving health plans.
Look for new tech-driven treatments because tech firms are increasingly developing digital therapeutics.
⭐ Just for Fun
The Deep Dive
December creates more revenue risk than any other month
Schedules fill up fast this time of year, and many patients try to get in before their deductibles reset. While that influx is great for volume, the fast pace can lead to rushed registration and small oversights, like missing an out-of-network alert or not noticing that a deductible still applies to in-office procedures.
Even when eligibility shows “active,” it doesn’t guarantee the visit or procedure will be covered. This is seen year-round, but the pace of December makes it easier for these nuances to slip through.
A common scenario can look like this: A patient comes in for a skin check. The provider sees something concerning and performs a biopsy or excision. Intake collects the copay, unaware that the procedure may fall under a different benefit category. When the claim adjudicates, the patient ends up with an unexpected balance. By January, after they’ve mentally closed out their healthcare spending, those balances become harder to collect.
To avoid this, it’s helpful to have a clear workflow for patients with remaining deductibles and a CCOF policy that allows the correct amount to be collected once the claim processes, without needing to estimate upfront.
Documentation challenges
When a provider sees a high volume of patients daily, reliance on EMR templates naturally increases. This is where small gaps can appear, especially around Modifier 25.
If a skin check evolves into the destruction of an actinic keratosis, for example, the documentation must clearly support that a separate E/M service occurred that day. During hectic periods, details like this can easily be missed.
A biopsy note without an indication or an excision note without a final size may not seem critical in the moment, but coders notice the impact immediately. When pathology reports arrive in January, any disconnect between the original note and the findings gives payers a reason to review medical necessity.
Staffing fluctuations
December is typically a high PTO month. For a startup or small practice, having a lead biller or intake coordinator out for even a week creates an operational gap.
Verification steps often fall to newer staff or temporary coverage who may be less familiar with specific plan nuances. In a lean practice, limited availability of key staff during a high-volume stretch can create bottlenecks that extend into Q1.
The compounding pressure on RCM
All of these upstream factors eventually impact the billing team. RCM ends up managing two competing priorities:
Clearing the backlog: Addressing missing notes, documentation questions, and coding gaps.
Preparing for the new year: Updating fee schedules, loading new CPT codes, and managing plan-year resets.
When they’re occupied with cleanup, it’s difficult to fully prepare for January. This creates a compounding effect: unbilled encounters may accumulate, DNFB (Discharged Not Final Billed) days may rise, and reimbursement can slow just as practices need cash flow to offset the quieter start of the new deductible year.
How to protect your revenue cycle
To protect your revenue cycle during this busy stretch, consider the following:
Verify at the procedure level: Encourage your intake team to move beyond global “active” checks. If a visit has the potential to turn into a procedure, confirm whether the plan treats office visits and minor surgeries differently without attempting to estimate exact costs upfront.
Audit your templates: Review high-volume templates to ensure they prompt for the medical necessity details payers require. If the template requests it, providers are less likely to rely on memory during a busy clinic.
Follow a 48-hour rule: Aim to resolve coder queries within 48 hours. This helps ensure December charges are processed in December, preventing them from overlapping with January’s fee schedule changes.
Consider a CCOF policy for January 1: Since estimating patient responsibility without payer fee schedules or MPR rules can lead to over-collection and refunds, a Credit Card on File (CCOF) workflow reduces the guesswork. It allows the practice to process the correct amount once the claim adjudicates, reducing administrative friction.
Bottom line: December’s pace creates small upstream gaps that compound quickly. Strengthening intake checks, reinforcing documentation, and tightening workflows now helps keep cash flow steady through the end-of-year rush and into the new plan year.
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That’s it for this week.
This one was super fun. Hope you enjoyed it too.
