Physician practices are experiencing a sharp increase in systematic downcoding by major commercial payors. This trend, driven largely by AI-powered algorithms, is resulting in significant revenue loss, higher administrative burden, and frustration for practices.

Cigna is significantly changing its commercial reimbursement policy for the Evaluation Management Service policy. This change goes into effect on October 1, 2025.

A $2.8 billion dollar class-action anti-trust settlement was reached between the plaintiffs (physicians, hospitals, large health systems, and provider organizations) and the Blue Cross and Blue Shield system (BCBS).

The Centers for Medicare & Medicaid Services (CMS) released their proposed rule on July 14, 2025 that will impact Medicare physician payments beginning January 1, 2026.

Medicare will have two separate conversion factors in 2026.

Medicare Advantage Plans are one alternative for Medicare beneficiaries in place of Medicare Part B (traditional Medicare). Most Medicare Advantage (MA) plans offer additional benefits such as Medicare drug coverage, dental coverage, and other types of services to Medicare patients beyond the usual coverage under the Medicare Fee for Service program.

It is not too early to begin preparing for the new Category III CPT codes, which will be implemented on July 1, 2025. As a reminder, Category III codes are temporary codes created for emerging technologies, procedures, and other services.

Staying up to date on the ever-changing regulations and requirements of coding and documentation can be challenging.

Here are some essential ways that everyone from clinical providers to coders,  billing and revenue staff,  compliance, and even IT personnel can help ensure that the organization as a whole operates in an effective, profitable and legally compliant manner.

Did you know the OIG has set the accuracy rate at 95%? In every setting, documentation begins and ends with the physician. Medical coding audits are a significant part of maintaining compliance. According to the recommended OIG Compliance Plan for Physician practices, auditing and monitoring are critical to ensuring compliance.

Where do providers stand on Skin Substitute Products?

CMS has delayed the final LCD coverage policies for skin substitute products for the treatment of diabetic foot ulcers and venous leg ulcers until January 1, 2026. The MACs initially proposed LCD L35041 to be released in April 2025 for Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers.

On March 14, 2025, the Continuing Resolution (CR) approved significant extensions for telehealth flexibilities and reimbursement policies that were set to expire on March 31, 2025.  This Continuing Resolution (CR) allows for the  Extension of telehealth waivers and the hospital-at-home program through September 30, 2025.  This provision will allow telehealth services to allow for the pandemic-era telehealth flexibilities that were set to expire on March 31, 2025, to continue until September 30^, 2025.