Welcome to “Vital Signs,” your go-to monthly roundup of all things related to RCM tailored for private practices and medical billers. Access previous editions for top insights and developments.
April was a busy month of news developments related to prior authorizations, Affordable Care Act (ACA) enrollment, behavioral health utilization, and more. Below is a summary of eight noteworthy stories. Consider reviewing them and discussing the possible effects on your medical practice or billing company.
1. States say undocumented Medicaid enrollees aren’t common
Details: As President Trump requires states to revalidate Medicaid providers and determine whether Medicaid enrollees are ineligible based on immigration status, findings from five states confirm that many of the Medicaid enrollees are indeed US citizens.
Why it matters: Based on these preliminary findings, intensified Medicaid eligibility audits are unlikely to uncover significant fraud. However, these audits — and new validation requirements — may still create administrative burden, coverage disruptions, and potential access barriers for eligible patients. Many states already face Medicaid staffing shortages that some say could pose even more challenges.
What’s next: Prepare for ongoing Medicaid eligibility scrutiny by:
- Strengthening front-end verification workflows,
- Proactively supporting patients through coverage changes, and
- Closely monitoring payer mix shifts to protect access and revenue continuity.
2. Three large Medicare Advantage insurers publish prior authorization denial rates publicly
Details: As of April 1, UnitedHealthcare, Humana, and Aetna have published approval rates, denial rates, and turnaround times for prior authorization decisions, as well as the outcomes of appeals for medical items and services (excluding drugs) on their websites.
Why it matters: Publicly disclosed rates come against the backdrop of a growing payer commitment to standardize and simplify prior authorizations. So far, efforts seem to be working. A recent press release from America’s Health Insurance Plans (AHIP) cited an 11% reduction in prior authorizations across a range of medical services. The reduction equates to 6.5 million fewer prior authorizations for US patients.
What’s next: Leveraging publicly available data, physicians can take the following steps to reduce denials, accelerate approvals, and strengthen contract negotiations:
- Benchmark payer performance
- Identify high-friction plans
- Redesign prior authorization workflows
3. CMS proposed rule streamlines the process for drug prior authorization
Details: A newly published proposed rule requires impacted payers to support electronic prior authorization, make decisions on requests within shorter timeframes that align with CMS programs, and increase transparency for the prior authorization of drugs.
Why it matters: The impact of this proposed rule could include:
- Timelier patient access to medications,
- Reduced administrative burden, and
- Improved overall revenue cycle performance.
What’s next: Ensure your EHR or revenue cycle management systems can support FHIR-based electronic prior authorization that will eventually become the standard. Also, incorporate real-time benefit checks and prior authorization requirements earlier (ordering/prescribing stage) to prevent downstream delays, as faster payer turnaround times (e.g., ~24–72 hours) become expected.
4. ACA enrollment continues to decrease
Details: ACA enrollment decreased by 17% to 26%, according to a new report. This comes in the wake of rising healthcare affordability challenges for 61% of Americans.
Why it matters: Experts say sicker consumers kept their coverage, leading to a deterioration in the risk pool and prompting questions for insurers over future ACA pricing.
What’s next: Insurers may raise premiums and enforce stricter utilization controls due to a less healthy ACA risk pool. Therefore, it's essential to:
- Improve eligibility verification,
- Prepare for increased denial rates, and
- Actively assist patients with affordability and maintaining continuous coverage.
5. Prior authorizations continue to challenge practices, according to MGMA
Details: Nearly all (90%) of practices report an increase in prior authorization in the last 12 months, according to MGMA’s 2026 regulatory burden report. Medicare Advantage requirements and quality reporting are two additional issues causing practices to divert time and resources away from patient care and into administrative tasks, the report found.
Why it matters: Pulling clinical and financial resources away from patient care drives:
- Higher staffing costs,
- Slower throughput,
- Increased burnout, and
- Greater risk of delays, denials, and lost revenue.
What’s next: Streamline workflows and invest in automation, when possible, to reduce administrative burden.
6. Consumer-facing AI tools continue to grow despite accuracy concerns
Details: Only 18% of consumers say chatbot-provided health information is accurate, according to a recent poll. Americans are more likely to have confidence in the accuracy of the health information they get from healthcare providers and major health websites than from other sources. However, this hasn’t deterred technology companies from continuing to expand artificial intelligence (AI) health offerings.
Why it matters: Low trust in chatbot-generated health information reinforces the physician’s role as the most credible source. Physicians must continue to guide patients through AI-influenced decisions as these tools continue to expand.
What’s next: Proactively address AI-driven misinformation by:
- Guiding patients to trusted sources,
- Incorporating brief digital literacy counseling into visits, and
- Establishing clear workflows for evaluating and correcting chatbot-generated health advice.
7. Behavioral health utilization on the rise
Details: Between 2018 and 2024, behavioral health utilization increased nearly 63%, according to a new report. In addition, since 2018, the proportion of telehealth volume attributed to behavioral health has increased from 18.4% to 65.6%.
Why it matters: Behavioral health is becoming the dominant telehealth use case, forcing physicians to rethink care models, staffing, and revenue strategy.
What’s next: Integrate behavioral health into core care delivery, particularly as federal efforts to examine worsening mental health outcomes ramp up:
- Expand telehealth access,
- Align workflows and staffing, and
- Tighten documentation and coding to sustain reimbursement and meet rising demand.
8. WISeR model causing denials and delays in some states
Details: Members of Congress say the WISeR model has caused unnecessary delays and denials during the first few months of its pilot program in six states.
Why it matters: Early delays and denials tied to the WISeR pilot could signal more administrative friction, slower payments, and higher clinical risk for physicians.
What’s next: To mitigate delays and revenue disruption as the model evolves:
- Proactively tighten documentation,
- Standardize prior authorization workflows, and
- Closely track denial patterns.
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