ADAM 2026 in Chicago packed the exhibit floor as well as the agenda, but the conversations worth your attention were in the hallways, the hotel bar, and the cluster of people who wouldn't let a session speaker leave the room.

Here are five things we kept hearing, and what they mean for your practice.

Someone said it plainly: the business of comparing what payers owe you to what they actually pay is a billion-dollar opportunity, and almost nobody does it well.

There's a reason.

Commercial payer fee schedules are functionally opaque. Medicare publishes the MPFS. Commercial plans often do not. Rates may reference a percentage of Medicare, a proprietary benchmark, or contract-specific carve-outs that aren't clearly itemized. Many practices don't have a clean, centralized copy of every executed contract. Even when they do, reimbursement exhibits are frequently missing, outdated, or written in ways that make true line-level comparison difficult.

That lack of contract transparency isn't accidental. It creates friction around validation. And payers count on that friction.

The cost of not looking is real. A JAMA Dermatology study found the charge-to-payment ratio for derm services hit 2.05 in 2019, increasing 3.25% annually. One case study recovered 1,700 underpaid derm claims in 6 weeks, with payments averaging 9% below contracted rates. At $118 per reworked claim, most practices just absorb the loss. When Medicare represents 30-60% of your revenue, even small fee schedule misalignments compound fast.

Here's what makes this hard: perfect contract-level validation requires clean contracts, clear fee exhibits, and structured rate tables. That foundation rarely exists. Obtaining contracts can take months. Some payers won't release fee schedules directly. Others reference dynamic benchmarks that shift annually.

That doesn't mean you're powerless.

Even without perfect contract data, reimbursement anomalies can be identified. Trend analysis across CPT codes, payer mix comparisons, Medicare-relative benchmarking, and denial pattern reviews all surface underpayment risk long before a formal contract audit is complete.

The real blind spot isn't "we don't audit every line item." It's not building systems that flag reimbursement behavior falling outside expected norms. That's where disciplined billing operations matter most.

Every billing conversation at ADAM eventually circled back to Aetna.

Aetna rolled out a nationwide E/M Claim and Code Review program targeting providers whose 99214 and 99215 billing patterns look like "outliers" compared to peers. The catch: they auto-downcode without reviewing medical records first. No phone call. No documentation request. Just a lower payment on the EOB.

The AMA published appeal templates opposing the practice. APMA formally engaged Aetna. The California Medical Association won standing to sue. Multiple specialty societies have issued joint letters.

A 2024 Medicare audit found actual overcoding at just 0.13% of 99214/99215 claims. Aetna's downcoding program targets roughly 3% of providers. That's a 23x wider net than the data justifies.

Downcoding from a 99214 to a 99213 costs you $30-40 per claim. For a practice billing 2,000+ E/M claims per year, the revenue hit adds up. But the real cost is the appeal burden: diverted staff time, delayed payments, and the documentation overhead that follows.

A Mohs surgeon told us their billing company's response to declining reimbursement was a shrug. "That's just how it is."

It's not just how it is. It's how billing companies avoid accountability.

Yes, Mohs reimbursement is declining. Inflation-adjusted rates for CPT 17311 have dropped 46% since 2007. CMS first-stage head/neck/hands reimbursement fell from $665 to $644 between 2024 and 2026. Derm denial rates run 11.8-14%, roughly double the average across specialties.

But "just how it is" isn't a reimbursement problem. It's a billing company quality problem. No published benchmarks compare collection rates between derm billing companies. That means there's no public accountability for the billing company telling you your numbers are normal.

The bar for "good enough" is dangerously low when nobody measures it. Practices evaluating their ASC economics or Mohs workflow should be asking what their billing company is doing to fight back, not just what rate CMS set.

The biggest presence came from patient engagement and communication companies: NextPatient, Vital Interaction, PatientPoint. ModMed had a single table. Nextech had a single table. The patient engagement vendors outinvested the EHRs.

AI was everywhere in the pitch decks. The reality was thinner.

AI adoption in healthcare hit 22% in 2025, up from 3% in 2023. But that adoption clusters around the easy stuff: phone systems, scheduling, patient outreach. Ambient scribing is at 92% adoption among health systems. Billing automation jumped from 36% to 61%.

The hard problems, coding accuracy, denial management, complex clinical workflows, are still mostly manual. And 80% of healthcare AI initiatives fail due to strategy and execution gaps, not technology limitations.

ADAM dedicated a session to "Driving Change: Even When Providers Push Back," which tells you where things actually stand. The biggest AI blocker in a practice isn't the algorithm. It's the provider who won't use it.

Meanwhile, AI startups and PE scouts were working the hallways, not the exhibit floor. That's worth watching.

Patient reactivation was one of the largest vendor categories at ADAM.

The math explains why. The average derm clinician has 1,000 to 2,000 lost patients, each worth $509.98 in annual revenue. Reactivating even a fraction of that is serious money. Bonsai claims $27.9 million generated across their customer base. Brevium cites a 25:1 ROI.

But here's what nobody on the exhibit floor was saying: 67% of patients leave because of bad experience, not medical reasons. Patients who miss one appointment are 70% more likely not to return within 18 months. Practices lose roughly half their patient database over five years.

Reactivation software fixes the symptom. It does not fix why patients left. A 5% increase in retention boosts profits 25-95%, and it's 5-25x cheaper than winning patients back.

When you're ready for an expert to make your practice's billing bulletproof, schedule a strategy call with our team.

This one was super fun. Hope you enjoyed it too.