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.

It has been a busy month of revenue cycle news related to the calendar year 2026 Medicare physician fee schedule proposed rule, a major overhaul of the Affordable Care Act, new efforts to streamline prior authorizations, and more. Take the time to review these news developments and discuss potential impacts on your medical practice or billing company.

The specifics: On July 14, 2025, CMS published its CY 2026 Medicare physician fee schedule proposed rule that includes an overall pay raise (3.8% increase) for physicians. 

Why it matters: After 5 years of payment cuts, industry experts say this is a welcome change. 

What’s next: Familiarize yourself with this rule and be sure to comment on proposed changes. Here’s a helpful topline summary from the AMA. Comments are due September 12, 2025.

The specifics: A coalition of cities, doctors, and small business advocates recently filed a lawsuit to block the ACA final rule set to take effect August 25. 

Why it matters: The coalition says the final rule imposes new fees, weakens coverage standards, and sets barriers that will make it harder — and in some cases impossible — for people to get and stay covered by insurance. The coalition also says the policy would disproportionately harm low-income families, communities of color, and patients with chronic or serious medical needs.

What’s next: Industry experts and associations continue to voice concerns, including worries about sweeping changes to Medicaid outlined in the One, Big, Beautiful Bill enacted July 4, 2025. Be sure to read our previously-published article on how physicians can prepare for cuts to Medicaid.

The specifics: The Centers for Disease Control & Prevention recently posted the FY 2026 ICD-10-CM guidelines for coding and reporting that take effect October 1, 2025. 

Why it matters: Updates to the guidelines include clarifications for coding HIV, coding for conditions involving multiple sites, Type 2 diabetes in remission, and more. 

What’s next: Review the guidelines and ensure physicians and medical coders are aware of important changes that affect common diagnoses. 

The specifics: CMS recently announced it would test a new model for health insurance prior authorization requirements to determine whether enhanced technologies, including artificial intelligence, can expedite the prior authorization processes for select items and services.

Why it matters: This model — termed the Wasteful and Inappropriate Service Reduction Model (WISeR) — has the potential to reduce administrative burden while simultaneously preventing unnecessary or inappropriate services with little to no clinical benefit.

What’s next: Stay tuned for additional details. The model launches January 1, 2026, and the model performance period ends December 31, 2031.

The specifics: America’s Health Insurance Plans — a national trade association representing health insurance providers — recently announced it would accelerate prior authorization decision timelines, increase prior authorization transparency, and expand access to affordable, quality care. 

Why it matters: With this commitment, patients may experience faster, more direct access to appropriate treatments and medical services, and providers may benefit from a more efficient and transparent process overall. The announcement comes in the wake of a recent study indicating that ‘‘gold card” programs designed to streamline prior authorizations do not achieve the goal of reducing administrative burden. 

What’s next: Humana recently announced it would eliminate approximately 1/3 of prior authorizations for outpatient services by January 1, 2026. The American Medical Association (AMA) continues to advocate for prior authorization reform. Stay tuned for additional announcements and developments. 

The specifics: CMS recently alerted providers to a new fraud scheme in which scammers impersonate CMS and send phishing fax requests for medical records and documentation, falsely claiming to be part of a Medicare audit.

Why it matters: Providers who fall for this scheme put patient information at risk. The agency says CMS never initiates audits by requesting records via fax.

What’s next: If you receive a suspicious request, do not respond. If you think you received a fraudulent or questionable request, CMS recommends working with your Medical Review Contractor to confirm whether it’s real.

The specifics: A federal judge in Texas recently ruled that medical debt may remain on Americans’ credit reports, cancelling a policy that the Biden administration created to help relieve the burden of healthcare expenses weighing on nearly a third of the population.

Why it matters: The Consumer Financial Protection Bureau anticipated that removing medical debt from consumer credit reports would increase the credit scores of millions of families by an average of 20 points. Even before the rule, Equifax, Experian, and TransUnion began removing unpaid medical collections under $500 in 2023. However, some said removing medical debt would have a negative effect on providers’ ability to collect patient balances.

What’s next: Given the rising cost of healthcare services, providers should continue to explore payment plans, patient financing programs, and patient financial counseling. 

The specifics: The American College of Physicians (ACP) recently published a policy paper that includes recommendations to standardize methods of risk adjustment, develop validated methods to measure the cost of caring for patients who experience health care disparities and inequities, leverage advanced analytics and machine learning, and more. 

Why it matters: According to the ACP, the existing approach to risk adjustment requires significant physician time and extensive documentation, necessitating the need for improvement and refinement.

What’s next: Stay tuned for additional developments and discussions around risk adjustment in healthcare. 

The specifics: Eye Consultants of Pennsylvania, PC agreed to pay $790,000 to resolve False Claims Act allegations of civil liability for submitting claims to Medicare for Evaluation & Management (E/M) services that violated Medicare rules and regulations. Specifically, the group reported E/M services on the same date of service for beneficiaries receiving bilateral eye injections when it was not justified to do so.

Why it matters: Without proper oversight, medical coding and billing errors like this can easily fly under the radar, putting medical practices at risk for costly fines and penalties.

What’s next: It may be beneficial to review E/M guidelines within your own medical practice and ensure providers understand what constitutes separately identifiable E/M services along with supporting documentation and proper modifiers. Here’s a modifier -25 resource from the AMA that can help.

The specifics: A recent study found that the annual physician exit rate from Medicare increased from 1.8% in 2010 to 3.6% in 2023. Primary care physicians had the highest exit rate of any specialty group in 2023 at 4.41%.

Why it matters: Physician exits from traditional Medicare could compromise access, affordability, and continuity of care for millions of older and disabled Americans.

What’s next: If you’re planning to exit traditional Medicare, you’ll need a clear plan to diversify payer mix or implement a direct contracting model. If you plan to stick with Medicare, optimizing revenue cycle operations will be paramount. Think through the decision carefully.

The specifics: A recent study found that 65% of individuals accessed patient information online at least once in the past year, up from 57% in 2022.

Why it matters: The increase may reflect targeted efforts to make it easier for patients to manage their health information electronically. It may also reflect greater engagement from providers.

What’s next: Continue to educate patients on the availability of tools and resources to manage and share their health information. 

The specifics: An observational quality improvement study of patients and clinicians using AI-driven ambient documentation tools found that informed consent emerged as a critical yet complex component of successful implementation. 

Why it matters: Informed consent helps ensure that ambient documentation enhances, rather than detracts from, the quality of patient care. 

What’s next: Researchers say providers should use an opt-in approach, with clear communication about the technology’s capabilities and limitations.

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