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.

Healthcare affordability continues to take center stage amid claim denials, prior authorization questions, and patient access challenges. Below is a summary of 10 significant revenue cycle management (RCM) stories impacting independent medical practices and billing companies.

Details: One in 3 Americans is cutting back on daily living expenses so they can afford healthcare, a recent survey found. In addition, with the expiration of enhanced premium tax credits, 1 in 10 Affordable Care Act (ACA) enrollees in 2025 is now uninsured. Half of those remaining in the ACA marketplace say their healthcare costs are ‘a lot higher’ this year. 

Why it matters: Rising patient financial strain directly translates to delayed care, lower patient volumes, higher bad debt, and slower collections. This ultimately puts pressure on cash flow and financial stability.

What’s next: Shift from reactive billing to proactive, patient-centered financial workflows to maintain revenue as affordability pressures intensify. Verify eligibility and benefits in real time (at scheduling and day of service) and confirm patient responsibility before care is delivered. 

Also, offer simple, plain-language estimates that show these details to reduce confusion and increase the likelihood of payment: 

Details: Insurers of qualified health plans sold on HealthCare.gov denied 19% of in-network claims in 2024 and 37% of out-of-network claims for a combined average of 20% of all claims, according to a recent report. These results are similar to those published in 2023.

Why it matters: High and persistent denial rates can create significant revenue leakage, increase administrative burden, and delay cash flow, all of which small practices are not equipped to absorb.

What’s next: Focus on proactive denial prevention. In particular, leverage automation/RPA for these tasks to reduce manual work and speed resolution:

Details: The Medicare Payment Advisory Commission (MedPAC) recently recommended an additional 0.5% payment update on top of the 0.75% update for qualifying clinicians in advanced alternative payment models (APM), and a 0.25% payment update for all other clinicians.  

Why it matters: Even with MedPAC’s recommended bump, Medicare payment updates remain modest and often fail to keep pace with rising operating costs. Practices must find ways to absorb margin pressure.

What’s next: Quantify what a 0.25%–0.75% (or slightly higher) update actually means for your revenue vs. rising costs (staffing, supplies, tech) to understand your true margin gap. Also, focus on investing in the following to maintain margins without adding headcount: 

Details: If finalized, a new proposed rule would remove 34 EHR certification criteria and revise certain certification requirements.

Why it matters: Experts say these changes would shift technical, operational, direct and indirect costs, and compliance responsibilities downstream to medical groups.

What’s next: Ask your EHR vendor what functionality, compliance safeguards, or reporting capabilities may change, and what the vendor will (or won’t) support going forward.

Details: Over 80% of physician respondents currently use AI in a professional context, which is double the share reported in 2023, according to a recent AMA survey. Most current use and excitement is centered on documentation and summarization applications.

Why it matters: Practices that adopt AI well can reduce administrative burden and improve productivity, while those that don’t adopt it at all (or implement it poorly) risk: 

What’s next: Focus on AI use cases such as documentation, summarization, and inbox management, where the return on investment is clear and clinical risk is manageable. Always keep a human in the loop. Require physician review and sign-off on all AI-generated documentation to protect accuracy, coding integrity, and compliance.

Details: In 2024, mostly specialist providers billed code G2211, generating about $394 million in payments, according to a recent analysis.

Why it matters: Widespread use of add-on code G2211 signals a meaningful opportunity to capture additional revenue for complexity. But it also raises audit and compliance risk if documentation doesn’t clearly support its use, especially for smaller practices with limited compliance infrastructure.

What’s next: Focus on compliance. Ensure notes clearly reflect these factors, and not just the visit itself: 

Also, conduct internal reviews to validate appropriate use and identify patterns that could trigger payer scrutiny.

Details: For independent physicians participating in risk-based contracts, physician-led interventions (e.g., decision support, incentives, care management) can reduce utilization and costs. However, the impact is generally modest and unlikely to significantly lower total spending on its own, according to a recent analysis. Researchers say there is a striking scarcity of high-quality studies on physician-mediated interventions to manage total medical expenditures. 

Why it matters: It highlights a fundamental mismatch: Physicians are increasingly held financially accountable under risk-based contracts, yet physician-led interventions alone don’t meaningfully bend the cost curve under them.

What’s next: Consider investing in the following to manage financial risk and achieve sustainable performance:

Details: Some physician practices are charging patients for prior authorization requests or requiring annual administrative fees for such requests and letters of medical necessity, among other services.

Why it matters: Charging for prior authorizations and administrative tasks may help offset uncompensated work, but it also introduces potential risks in these areas that could impact retention and reputation:

What’s next: Approach administrative fees carefully, balancing revenue needs with patient trust and compliance. Consider investing in automation and streamlined prior authorization workflows to minimize the need for fees in the first place.

Details: According to new research, the top queries from AI users are: 

Nearly a third also use chatbots for insurance or provider searches.

Why it matters: As patients increasingly use AI as a first point of contact for clinical and administrative questions, they develop new expectations around access, speed, and transparency. Practices that don’t meet these expectations risk losing patient engagement, trust, and even volume to more digitally responsive competitors.

What’s next: Be prepared to confirm, correct, or contextualize information patients bring from chatbots without dismissing it. Differentiate from AI by emphasizing personalized, longitudinal care and clinical judgment.

Details: For patients, the inability to see a doctor quickly is the number one source of frustration, according to a recent survey. For providers, it’s insurance discovery — improving the speed, accuracy, and completeness of insurance searches.

Why it matters: Delays in access and inefficient insurance discovery directly affect both patient satisfaction and revenue. This leads to lost visits, higher front-end errors, increased denials, and slower cash flow.

What’s next: Fix access and front-end workflows simultaneously. Use these tools to open more timely appointment slots:

In addition, implement real-time tools to verify coverage, benefits, and payer details before the visit to reduce errors and denials.