A Message from David: As we close the first quarter of 2026, one thing is becoming increasingly clear: the revenue cycle environment is not volatile — it is tightening. Denial rates remain elevated, holding near the 11–12% range across many specialties. Prior authorization timelines have shortened, increasing documentation pressure upstream. Reimbursement adjustments are modest, yet administrative intensity continues to rise.
Revenue Protection in a Split-Reimbursement Year Revenue Leakage Is Now a Board-Level Variable A Message from Gene: In 2026, revenue leakage is no longer a billing clean-up exercise. It is a direct operating margin variable. Across the industry, preventable breakdowns continue to drain an estimated 3–5% of net revenue annually. In a tightening reimbursement environment, that leakage is often the difference between margin stability and monthly deficit.
A Message from Gene Spirito In today’s environment, staying “mostly compliant” or “reasonably efficient” just isn’t enough. I speak with revenue cycle leaders every day who are trying to answer the same questions: “What’s changing in 2026?” “Where are we vulnerable?” “How do we keep revenue predictable?”
What Is MACRA?
There are many aspects of MACRA, and it's important you're familiar with all of them.
Looking Back. Moving Forward. Supporting You Every Step. Reflecting on 2025, preparing for 2026 — and strengthening the future of healthcare together. As 2025 draws to a close, healthcare practices and laboratories across the country are reflecting on a year marked by profound change — from regulatory reform and financial pressure to rapid shifts in technology. No matter your specialty — whether it’s primary care, imaging, behavioral health, addiction treatment, orthopedics, podiatry, neurology, wound care, or laboratory services — the demands of 2025 likely challenged your operations, your team, and your bottom line.
Chat Bott, MD The patient has just received medical advice without speaking with a provider, without a telemedicine session, and without being in an emergency room. Instead, the patient has consulted with Drs. Google and ChatGPT. According to a recent (November) New York Times article, one in six adults - and a quarter of those under age 30 - regularly consult AI mechanisms such as ChatGPT for medical advice. The article says common sentiments of those surveyed were (1) they weren’t getting what they needed from their medical community, (2) wait times are too long, (3) doctors aren’t attentive, and (4) costs are unaffordable.
2026 CPT® to Include AI-Related Codes For 2026, you can look forward to a new coding system that provides better documentation of “technology-enabled care,” which includes remote patient monitoring (RPM), digital health services (e.g., telehealth and wearables), and medical services enhanced or augmented by AI. This is all courtesy of the AMA, which recently released its 2026 CPT code set, comprising 418 total changes, including 288 new codes, 84 deletions, and 46 revisions to existing codes.
Be WISeR: Expect CMS to Increase Prior Authorizations Through its Wasteful and Inappropriate Service Reduction (WISeR) model, this newly announced initiative by CMS is aimed at reducing what it says is expensive, unnecessary care as covered by original Medicare. It’s designed to protect federal taxpayer dollars. According to CMS, “wasteful care” includes services provided to patients that yield no clinical benefit which can also put patients at risk for unnecessary procedures.
The Proposed 2026 Physician Fee Schedule (PFS) has Two Separate Conversion Factors Have you been watching your Ps and Qs on value-based (VB) care? Because Medicare’s 2026 physician reimbursement will be more closely tied to VB care, site-neutral payments, and more resourceful delivery of services. That said, there will also be another instance of it for providers who do not follow VB care.
Uncompensated Care to Increase Uncompensated care primarily affects hospitals, with an estimated $85 billion in uncompensated care projected between 2025 and 2034. However, non-hospital physicians would see an estimated increase of $34 billion in uncompensated care. Pharmacies would stand to see $56 billion in uncompensated prescription medications.