RCM Newsletter: November 2025 InSights

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.

With Dr. Chat Bott, on the other hand, there’s no wait time and therefore, no waiting room, no 15-minute appointments that seem rushed, the information is basically free, and perhaps most eye-opening, respondents said their concerns “are finally being heard.” You read that correctly. And the article includes examples of patients’ communications with their providers, expressing annoyance that issues Dr. Bott pointed out weren’t mentioned by their providers.

 

Then there’s this: while many online entities have explanations about how they’re not intended to provide medical advice, several have now removed their disclaimers about health questions.

 

An obvious takeaway is that you should probably assume your patient has consulted an online entity for their visit reason(s) or symptom(s), and be ready for that discussion.

 

Click here for the NY Times article; you might have to sign up to read it fully.

Surprise! It’s Providers who are behind Surprises

That’s at least according to a report from AHIP and BCBSA. Here’s the thumbnail:

 

A group of payers says they’ve identified one of the biggest abuses of the federal process for resolving surprise medical bills: it’s out-of-network providers submitting a large volume of ineligible claims. The report says that nearly 40% of surprise billing disputes as submitted to the independent dispute resolution (IDR) process were ineligible, even though many of the claims deemed ineligible still went to arbitration. It’s being called “arbitration abuse.”

 

In particular, providers submitting large volumes of these claims tended to be backed by private equity firms.

 

Per the No-Surprises Act (NSA), out-of-network providers and payers can submit surprise billing disputes to the IDR for review if the items or services on the claim are out-of-network emergency services, out-of-network non-emergency services provided at an in-network facility, or out-of-network air ambulance services.

 

The problem, per the report, is that of the 1.23 million surprise billing disputes submitted through the IDR process in 2024, approximately 39% were ineligible based on the requirements noted above, including 45% of non-emergency service disputes.

 

What were some common reasons payers identified claims as ineligible? Here’s the list:

 

• Claims included services payable under Medicare or Medicaid
• Disputes were already resolved through IDR and resubmitted
• Disputes involved in-network providers
• Claims were already subject to a state (not Federal) surprise billing law

 

What’s the private equity angle?

 

According to the report, out-of-network providers submitting large volumes of ineligible claims are apparently “gaming the system” for higher payments for disputed services.

 

The details, which are many, can be seen by clicking here for the AHIP report.

 

(We help our clients avoid surprises with access to a pre-appointment patient responsibility estimator, and by getting pre-appointment out-of-network alerts. Completing the circle are our pre-appointment eligibility verifications and an automated prior authorizations option!)

Final Physicians Fee Schedule for 2026

Not a minute too soon, CMS finalized a modest bump in the Medicare PFS for 2026. There are also new initiatives to promote chronic disease prevention and improve efficiency.

 

There will be two conversion factors, depending on whether the provider participates in a qualifying alternative payment model (APM).For those who do, the conversion factor will be increased by 0.75%. Those not participating will see a 0.25% increase.

 

The “in other words” explanation: providers in certain APMs will receive a $1.22 boost to the current conversion factor of $32.35. For the nonqualifying conversion factor, CMS said that it would increase by $1.05 to $33.40. (At least the word “boost” applies to both.)

More: The changes also reflect a one-year increase of 2.50%, and an estimated 0.49% adjustment for new modifications to the work relative value units (RVUs) for some services, as described in the new final rule.

 

On efficiency, CMS had always used physician survey data from the American Medical Association (AMA) to determine work RVUs and, in turn, the payment rates for services covered by the Medicare PFS. For 2026, the final rule won’t use AMA's survey data; it’ll instead use the Medicare Economic Index (MEI) to calculate productivity adjustments.

 

To prevent chronic disease, CMS plans to use a risk assessment code to focus on essential patient behaviors that reduce chronic disease and improve overall health for Medicare beneficiaries. These behaviors specifically focus on physical activity and nutrition.

 

Click here for all the details as they appear on the Federal Register, and here for a related CMS press release.

 

(Even with the bump, you’ll still want to ensure maximized revenue on your claims. That includes optimized E/M and HCC coding. We help our clients obtain the best reimbursements possible, which also includes powerful tools for ensuring patients pay their responsibility balances!)

A Word to the WISeR

The CMS Wasteful and Inappropriate Service Reduction (WISeR) effort will implement prior authorization (PA) in six states starting in January. Basically, AI would be used to create a need for PAs to reduce what is perceived as wasted revenue and resources on unnecessary procedures, or procedures that produce little to no results.

A bill was introduced during the week of 11/11 to repeal the AI-backed PAs.

 

Click here for details on WISeR and the effort to undo it.

 

(Regardless of the WISeR outcome, you’ll still want access to an automated PA option to replace the time-consuming effort needed by staff to deal with them manually. We have that!)

Ok TEAM, Ready for another Acronym?

They must pay someone to come up with these acronyms.

 

This one, also from CMS, is the Transforming Episode Accountability Model. Starting in January 2026 and applicable to hospitals and acute care centers, the report notes that 77% of healthcare quality leaders aren’t prepared for it.

 

The TEAM initiative aims to tie Medicare payments to quality of care and costs through a bundled payment structure.

There are plenty of details if you’re interested. Click here for the CMS overview.

 

(Speaking of bundling payments, we help clients comply with NCCI when multiple claims for a single patient should be bundled into one master claim, thereby avoiding avoidable denials!)

Fraud of the Month

On October 1, 2025, an AL-based doctor pleaded guilty in Federal court to a $6 million telemedicine fraud scheme involving medically unnecessary durable medical equipment (DME) and genetic testing primarily used to detect mutations in genes that could indicate a higher risk of developing certain types of cancers.

 

Between December 2018 and March 2021, the doctor worked with telemedicine companies to sign medical documentation, including doctors’ orders for medically unnecessary durable medical equipment and genetic testing. The orders were pre-populated based on telemarketing calls made to Medicare beneficiaries.

 

The doctor generally did not contact the beneficiaries himself and had no medical relationship with the beneficiaries.

 

DME suppliers and laboratories ultimately submitted claims to Medicare for these signed orders. As a result of his participation in this scheme, over $6 million in claims were submitted to Medicare for DME and genetic testing that were medically unnecessary, based on false documentation and tainted by kickbacks.

 

The doctor faces up to 10 years in prison and a fine of up to $250,000 at sentencing.

 

Click here for details from the DOJ.

Remote Patient Monitoring = $$$$$

According to a Health Affairs Study, primary care practices that adopted RPM from 2019 to 2023 saw Medicare revenue increase by 20% compared with practices that didn’t provide RPM to their patients.

 

Additionally, RPM-adopting practices increased by seeing 2.9% more patients each quarter. The study agrees with previous data showing that RPM utilization and spending within Medicare are growing rapidly.

 

The 2026 Medicare Physician Fee Schedule final rule (see article above) added new RPM billing codes that will pay healthcare practitioners for collecting RPM data for the first 10 minutes and for two to five days within a 30-day period. Current billing codes only pay practitioners for collecting at least 20 minutes of data and for 16 days of data collected every 30 days.

 

(Almost any specialty can benefit by providing patients with RPM. It combines convenience for them and less resource utilization for you. With telehealth, a powerful mobile/engagement suite is created. And, you can be paid for RPM and telehealth sessions. Our team can help you get there with our RPM option and our Medics Telemedicine app!)