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.

With open enrollment beginning November 1, the healthcare industry continues to face uncertainty as lawmakers debate whether to extend premium tax credits. Medical practices also face other uncertainties, particularly the processing of certain telehealth claims moving forward. 

It’s a stressful time that requires ongoing communication between providers and their revenue cycle management (RCM) teams. Here’s a roundup of 7 important news stories this month. Take the time to review them and discuss potential impacts on your medical practice.

The specifics: Hospitals, physicians, and other healthcare providers would face more than $32.1 billion in lost revenue in 2026 if enhanced premium tax credits expire, according to a new analysis by the Robert Wood Johnson Foundation. Consumers will spend $5.1 billion less on services provided by office-based physicians. In addition, physician offices will face $1.0 million in uncompensated care, the analysis found.

Why it matters: According to researchers, declines in healthcare spending coupled with subsequent declines in provider revenues could have a profound financial effect on providers and hurt access to care. Many practices would likely face higher self-pay/uninsured patient proportions, leading to increased financial risk and slower cash collections.  

What’s next: Now is the time to focus on patient financial risk mitigation. Strengthen patient eligibility checks, pre-visit estimates, payment plans, and point-of-service collections. Expense control, operational efficiency, and proactive patient financial education will also be critical.

The specifics: CMS has instructed all Medicare Administrative Contractors (MAC) to lift a previously imposed claim hold and process claims with dates of service of October 1, 2025 and later for telehealth claims that it can confirm are specifically for behavioral and mental health services. But the agency continues to temporarily hold claims for other telehealth services that are not definitively for behavioral/mental health. 

However, physicians in a Medicare Shared Savings Program Accountable Care Organization (ACO) may be exempt from claim holds, meaning they can still bill and receive payment for all standard Medicare-covered telehealth services, even though the broader national telehealth flexibilities expired on October 1, 2025.

Why it matters: Claim holds could disrupt cashflow, distort accounts receivable, increase administrative overhead, and create other financial and operational challenges. 

What’s next: Know what telehealth services may be affected by the temporary hold. Examples include services like follow-up visits, virtual check-ins, advanced care planning, or caregiver training conducted via telehealth where the patient is located at home or in a non-rural area, and the provider is not participating under an ACO telehealth exception. Then consider issuing an Advanced Beneficiary Notice if you anticipate Medicare may deny the service.

The specifics: NBC News spoke with several physicians who say payer downcoding often flies under the radar, causing significant revenue loss. Read the article here.

Why it matters: Payer downcoding not only strains payer-provider relations, it also increases administrative burden, erodes revenue, and encourages defensive coding that undermines accurate representation of patient acuity, affects risk-adjustment data, and reduces reimbursement across value-based contracts.

What’s next: Strengthen clinical documentation, track downcoding trends, and appeal strategically.

The specifics: Physicians have become increasingly consolidated as the share of physicians in practices owned by other entities has increased over time, according to a new GAO report.

Why it matters: In the absence of proactive planning, physicians who choose to remain independent may face reduced leverage in negotiations with payers and referral traffic diversion as large systems refer within their network.

What’s next: Focus on differentiation. Independent practices committed to remaining independent can differentiate themselves from others via the patient experience, personalized care, and efficient billing/revenue cycle management.

The specifics: Patients who are Black or Hispanic, dual-eligible for Medicare and Medicaid, or have limited English proficiency are less likely to receive a response within 1 day to their portal messages than White, commercially insured, English-speaking patients, according to a recent study.

Why it matters: Researchers say these findings underscore the importance of adequately equipping and resourcing clinics and care teams who care for underserved populations via EHR-based care modalities to avoid perpetuation of known healthcare disparities.

What’s next: Stratify message response times in your practice by race/ethnicity, insurance type, language preference, and socio-economic status to identify whether you experience similar differential delays. If you do, consider adjusting workflows and staffing to ensure equitable turnaround times and meet patient expectations. 

The specifics: In 2014, 28.6% of physicians were in a practice that participated in a Medicare ACO, which rose to 37.6% in 2024, according to the American Medical Association (AMA). 

Why it matters: While fee-for-service still dominates, the AMA report signals a fundamental shift in how healthcare is delivered, measured, and financed — one that has broad implications for quality, cost, and equity.

What’s next: Audit current payer contracts and revenue sources to determine what percentage of income comes from fee-for-service vs. value-based payment models. Then strengthen data infrastructure, analytics, care coordination, and patient engagement before revaluating and renegotiating payer contracts. 

The specifics: A recent study found that using an ambient AI scribe platform significantly reduces physician burnout, cognitive task load, and time spent documenting. After 30 days with the ambient AI scribe, participating ambulatory clinicians had 74% lower odds of experiencing burnout. A separate study found that AI scribes also improve documentation efficiency and reduce clinician workload. 

Why it matters: These findings suggest that AI may have promising applications and allow physicians more time for meaningful work and professional well-being.

What’s next: Measure the current clinician documentation burden in your medical practice (consider using the Mini Z assessment). Then consider selecting and piloting an ambient AI scribe tool. Be sure to choose a vendor that integrates with your EHR/PM system, ensures HIPAA compliance, and demonstrates a clear return on investment. 

Explore how Tebra's AI-powered tools work within your existing practice management workflow, maintain full security and compliance standards, and deliver ROI while reducing documentation burden and freeing your team to focus on patient care. Book a free, personalized demo today.