Welcome to “Vital Signs,” your go-to monthly roundup of all things related to RCM tailored for independent practices and medical billers. Access previous editions for top insights and developments.

Schools are back in session, summer has come to an end, and revenue cycle departments have been busier than ever trying to make sense of Cigna E/M policy changes, a $2.8 million Blue Cross settlement, potential rollback of telehealth flexibilities, and much more. 

However, it’s important to make time to review the news stories in this month’s recap and discuss potential impacts on your medical practice or billing company.

The specifics: A new study found that machine learning can use integrated clinical, geosocial, and environmental data to predict which patients will no-show, late cancel, and complete primary care visit appointments.

Why it matters: Machine learning may have the potential to enhance appointment management, improve patient continuity and outcomes, boost operational efficiency, and support tailored patient engagement strategies.  

What’s next: Understand your no-show problem. Then start with low-tech interventions (e.g., use text/email/phone reminders and confirm appointments ahead of time) before evaluating predictive tools. For high-risk patients, assign staff to call, offer rides, or double-book slots strategically.

The specifics: The AMA recently posted a 22-page physician’s guide to effective revenue cycle management that explains the importance of the revenue cycle and includes de-identified case studies and other strategies to improve performance. 

Why it matters: According to the AMA, physicians are often not educated on the mechanics or importance of RCM, which creates a vacuum in physicians’ understanding of the business of medicine.

What’s next: Use tools from the AMA guide to educate your team, foster cross-functional collaboration, keep an eye on policy changes, engage patients proactively, and monitor key performance metrics.

The specifics: A new analysis found that Affordable Care Act (ACA)-regulated health plans propose to increase premiums by 18%, which is about 11 percentage points higher than last year. This is the largest rate change insurers have requested since 2018. The analysis cites several reasons for the premium increases: rising healthcare costs, tariffs, and federal policy changes. 

Why it matters: Higher premiums may deter care, leading to worsening health and delayed presentations. In addition, elevated out-of-pocket costs can disrupt collections and increase uncompensated care.

What’s next: Anticipate increases in uninsured and underinsured patients if subsidies expire or premiums rise sharply, and update your practice’s financial projections to account for potential changes in payer mix. Other steps include strengthening patient financial counseling and increasing point-of-service collections.

The specifics: A new study found that ambient documentation technology (ADT), which develops artificial intelligence-drafted clinical notes from clinician-patient conversations, is associated with reductions in physician burnout and increases in perceived well-being.

Why it matters: This study offers a clear, evidence-based path for practices aiming to improve clinician well-being and operational efficiency.

What’s next: Explore potential solutions. Research EHR-integrated or standalone ambient documentation tools (e.g., ambient scribes). Ask vendors for demos, testimonials, and evidence of burnout reduction.

The specifics: Ninety-eight percent of small healthcare organizations falsely believe they’re HIPAA-compliant, according to a new report. What’s driving this startling number? A dangerous mix of outdated tools and deep misunderstanding of HIPAA requirements.

Why it matters: This report reminds us that small practices are not too small to be targeted, and ignorance or complacency isn’t a defense. Educate yourself and your staff. Tools like Microsoft 365 or Google Workspace, for example, often don’t provide end-to-end encryption by default. Both platforms encrypt data in transit and at rest; however, this is not the same as true end-to-end encryption.

What’s next: Regularly assess vulnerabilities, document procedures, and prepare incident response plans. Here are some additional cybersecurity tips that can help.

The specifics: On August 19, a US judge in Alabama granted final approval to a class action settlement requiring insurer Blue Cross Blue Shield to pay $2.8 billion to resolve claims by hospitals, physicians, and other health professionals that they were underpaid for reimbursements. 

The agreement also includes:

It also establishes a monitoring committee to oversee compliance and address any grievances.

Why it matters: The BCBS settlement is expected to benefit more than 1 million providers, and it represents one of the largest antitrust settlements in US healthcare history.

What’s next: Stay tuned for additional developments and next steps for providers who are eligible to receive part of the $2.8 billion in monetary relief and at least $17.3 billion in injunctive relief.  

The specifics: After reviewing Medicare remote patient monitoring claims, the OIG says CMS must implement more safeguards to ensure that remote patient monitoring (RPM) is used and billed appropriately in Medicare. 

In a summary of its findings, the OIG cites 2 measures CMS can use to identify medical practices billing for remote patient monitoring that warrant further scrutiny:

1. Billing for a high proportion of enrollees who have no prior history with the medical practice.

2. Billing for multiple monitoring devices a month for an enrollee.

Why it matters: This report builds on a September 2024 OIG evaluation that identified widespread RPM growth, incomplete monitoring components (43% of patients didn’t receive all 3 components), and a lack of transparency in ordering providers — highlighting vulnerabilities in program oversight.

What’s next: Audit your current RCM billing to check for these red flag patterns identified by the OIG:

The specifics: A new report found that providers are not prepared for Medicare telehealth flexibilities set to expire on September 30, 2025. 

More specifically, 71% of providers say their organizations are only “somewhat prepared” or “not prepared.” Nearly 62% of clinicians anticipate scheduling and care disruptions if waivers are not extended. And 89% worry about billing errors and reimbursement losses as rules change abruptly.

Why it matters: Your practice may be on the verge of significant disruption unless you act now. Developing a comprehensive plan will protect access, prevent financial losses, and preserve care continuity.

What’s next: Determine which services are at risk if waivers expire. Then prepare patient outreach for those relying on audio-only or home-based care to let them know they may need to transition to audio-visual methods and/or in-person settings.

The specifics: HHS and OCR recently published a new FAQ allowing providers to disclose protected health information to participants in value-based care arrangements, such as accountable care organizations, without an individual’s authorization. 

Why it matters: This clarification enables smoother, HIPAA-compliant care coordination, reduces administrative friction, and supports timely care.

What’s next: Update internal privacy policies and staff training to reflect this change, reducing unnecessary hesitation to share data for treatment in collaborative care models.

The specifics: A new Cigna policy effective October 1, 2025 allows the payer to adjust levels 4 and 5 evaluation and management (E/M) codes to a single level lower when the encounter criteria on the claim does not support the higher level E/M code reported. 

To receive the originally billed payment, providers will be required to file a post-payment appeal with full medical records to justify the initial coding.

Why it matters: Previously, Cigna required audits/record requests and manual intervention before downcoding. Now, Cigna is embedding the practice into its claims adjudication system as a routine reimbursement adjustment, placing the burden on providers to appeal if they believe a higher level is warranted.

What’s next: Several medical associations have already pushed back on the policy, saying it will increase administrative burden and create a barrier to appropriate reimbursement. In the meantime, revamp documentation workflows to ensure high-level E/M visits are thoroughly supported. In addition, pre-emptively review claims for codes 99204–99205, 99214–99215, and 99244–99245.

Learn how Tebra's integrated solutions can help your practice or billing company navigate these industry challenges, from automated billing and claims management to reduce administrative burden to comprehensive revenue cycle tools that streamline operations and improve financial performance. Book a free, personalized demo today.