Category: Newsletter

What Patients Expect From Healthcare in 2027 (and What It Means for Your Practice’s Revenue)

Posted on by Reviora Healthcare LLC in Newsletter

Reviora Healthcare LLC | Guaranteed Revenue Partner

Your next patient may decide whether to show up before they ever reach your front desk. In its 2022 Health Care Debt Survey, KFF found that 41% of U.S. adults carry debt from medical or dental bills, and those with debt were far likelier to put off care over cost (64% vs. 28%). Every postponed visit is a slot you staffed, scheduled and paid overhead on.

What will patients expect from your practice in 2027?

Three things: a price they can trust, digital access, and care decisions that don’t stall in a payer queue. That is our synthesis of the data below, not a single survey finding.

Digital access is already the norm. ASTP/ONC reports that 65% of individuals nationwide were offered and accessed an online medical record or patient portal in 2024, up from 57% in 2022. Provider encouragement matters: 87% of those encouraged by their provider accessed their portal, versus 57% of those who were not (ASTP/ONC, 2025).

Price confusion is where balances go unpaid. Among KFF respondents with debt, 68% had left a bill unpaid in full because they expected insurance to cover it, and 44% because they weren’t sure the bill was accurate (KFF, 2022).

Behavioral economists call the sting loss aversion: in Kahneman and Tversky’s prospect theory, losses weigh more heavily than equal gains (Econometrica, 1979). A surprise bill is a loss, which may help explain why indebted patients delay care. That is our interpretation, not a finding of either study.

How does patient cost uncertainty hurt practice revenue?

It hits collections and the schedule. Practices collected about 72% of copayments at time of service but only 26.83% of other patient-due balances (MGMA Stat, August 2026, citing the 2025 MGMA DataDive Financials and Operations report). Whatever isn’t collected at the desk has to be chased later.

The schedule shows strain too. In an August 11, 2026 MGMA Stat poll, 32% of medical groups reported higher no-show rates than in 2025, with some leaders pointing to patient costs. MGMA cautions that those were open-ended comments that can’t prove cause.

Will prior authorization be faster in 2027?

On paper, yes; in practice, not yet. Since January 1, 2026, CMS-0057-F has required Medicare Advantage plans and certain Medicaid and CHIP payers to decide urgent prior authorizations within 72 hours and standard ones within seven calendar days. Drug requests are excluded, and commercial plans outside the federal exchanges are not on CMS’s list. Payer prior authorization APIs (electronic connections that let systems exchange requests) are due January 1, 2027 (CMS, 2024).

Yet in MGMA’s September 1, 2026 poll, 44% of group leaders said turnaround got slower in 2026, 40% said about the same, and 7% said faster. Patients feel the delays: 95% of physicians in AMA’s 2025 survey said prior authorization at least sometimes delays necessary care (AMA, 2026). Treat 2027 as the year the rules improve, not the year your workload does.

What should specialty practices do before 2027?

Move the cost conversation before the visit, and give it an owner. MGMA advises verifying coverage and giving an estimate several days ahead, plus naming a contact for payment options (MGMA Stat, August 2026). For self-pay patients it is also federal law: CMS requires a good faith estimate within one business day of scheduling when care is booked three or more business days out, and within three business days when booked ten or more business days out or on request (CMS, No Surprises Act guidance).

This front-end work is what our specialists handle under Reviora’s Expert-Led Technology model: human specialists lead, technology supports. Start at our Services hub, then see Billing & Coding, Claims & Denial Management and AR Recovery, or your specialty RCM page. Our MOA is a written contractual performance agreement built on five benchmarks. Its Benchmark Recovery Protocol (BRP) is the accountability mechanism that starts after two consecutive missed months. Details are on The Reviora Guarantee page.

Want a second set of eyes on your front-end process? Book a 30-minute consult or visit Get Started.

FAQ

How do I reduce patient no-shows caused by cost?
Move the cost conversation earlier. MGMA recommends verifying coverage and giving an estimate several days before the visit, with a contact for payment options (MGMA Stat, August 2026).

Do practices have to give patients a cost estimate before a visit?
For uninsured and self-pay patients, yes: CMS requires a good faith estimate on the timelines above (CMS, No Surprises Act guidance). It is an estimate, not a bill. Insured patients fall under different rules, so confirm with counsel.

What is CMS-0057-F, and does it apply to my practice?
It is CMS’s interoperability and prior authorization rule. Its decision-time and API mandates fall on payers, not practices. For clinicians, it adds an Electronic Prior Authorization attestation measure to MIPS Promoting Interoperability beginning with the 2027 performance period (CMS, 2024).

What share of patient balances do practices collect at time of service?
About 26.83% of patient-due balances other than copayments, versus roughly 72% of copayments (MGMA Stat, August 2026, citing the 2025 MGMA DataDive).

References

Annual Wellness Visit Billing Errors That Trigger Automatic Denials

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Medicare denied 10% of all Part B claims on first submission in 2024 (CMS data reported by MedPAC, 2026), and wellness visits fail on dates before anyone reads the note. If an Annual Wellness Visit (AWV) claim breaks a timing rule, Medicare’s system rejects it automatically. The bigger risk is the AWV that gets paid but isn’t backed by the chart: Penn State Health agreed to pay $11,712,336 to resolve allegations over AWV claims that weren’t supported by the medical record (U.S. Department of Justice, 2024).

Which AWV billing errors does Medicare reject automatically?

The ones that break its timing rules, because Medicare’s Common Working File (the central database of every patient’s claims history) checks them by computer. Under CMS Transmittal 2575 (2012), it rejects a first AWV (G0438) if one was ever paid, any AWV within 12 months of a prior AWV, and any AWV within 12 months of a Welcome to Medicare exam (G0402).

It also rejects an AWV billed within 12 months of first Part B coverage. CMS’s current guidance repeats the core rule: G0438 and G0439 are billable once in a 12-month period (CMS, 2026). Hospital-affiliated clinics face one more trap: Medicare pays the practitioner or the facility for an AWV, never both (CMS, 2012).

How does Medicare count the 12 months between wellness visits?

By calendar month, not by days. Medicare counts 11 full months starting with the month after the last paid AWV (CMS Transmittal 2575, 2012). If a visit was paid on March 20, the patient is eligible again on March 1 of the next year, not March 20.

A scheduler set to 365 days will delay patients who are already eligible. One set to “about a year” will book patients too early, and the denial notice sent to the patient says the visit came too soon after the last covered one.

The fix happens at scheduling. Medicare’s systems keep a “next eligible” date for each patient (Transmittal 2575), so ask your Medicare Administrative Contractor (MAC, the company that processes your Medicare claims) which tool shows it, and check it when you book.

What goes wrong when an AWV and a problem visit happen on the same day?

Medicare may pay for both, but only if the second service is a significant, separately identifiable, medically necessary evaluation and management (E/M) visit, meaning a standard office visit code, reported with modifier 25 on the E/M line (CMS, 2026). The usual errors are no modifier, the modifier on the wrong line, or an E/M that can’t stand on its own medical necessity.

Add-on services have their own modifier rule. CMS waives patient cost-sharing for advance care planning (99497) and the physical activity and nutrition assessment (G0136) only when the same provider delivers them the same day and bills them with modifier 33 on the AWV claim (CMS, 2026). Without modifier 33, the waiver doesn’t apply.

Can an AWV be denied or clawed back after it’s paid?

Yes, if the chart doesn’t prove the required elements. CMS lists minimum components for every AWV, including a health risk assessment (HRA, a patient self-report questionnaire), updated medical and family history, a current provider list, measurements, a cognitive impairment check, and a written screening schedule (CMS, 2026).

CMS’s FY2025 report puts the Medicare fee-for-service improper payment rate at 6.55%, or $28.83 billion (CMS, 2026). Insufficient or missing documentation drove 68% of those errors (CMS data reported by MedPAC, 2026). CMS is clear that improper payments are not a measure of fraud (CMS, 2026). These figures cover all Medicare services, not AWVs alone, but the pattern fits: the code can be right and the claim can still fail if the note doesn’t prove the work.

What does a clean AWV workflow look like?

Check eligibility at scheduling, match the code to the visit type, and audit the note against CMS’s element list before the claim leaves your office.

At Reviora Healthcare, human specialists lead that work and technology supports them: Expert-Led Technology, applied across Medical Billing & Coding and Claims & Denial Management. The Reviora Guarantee puts performance in writing through a Managed Outcomes Agreement (MOA), a contractual agreement built on five benchmarks, with a Benchmark Recovery Protocol (BRP) as our accountability mechanism if benchmarks are missed two months in a row.

Wellness visits are core to Primary Care RCM, and any practice billing them can run these same checks. Want a second set of eyes on your AWV claims? Book a 30-minute consult or get started here.

FAQ

How often can you bill an annual wellness visit for Medicare?
Once in a 12-month period. Medicare counts 11 full months from the month after the last paid AWV, so a March visit makes the patient eligible again the following March 1 (CMS, 2012; CMS, 2026).

Can you bill an annual wellness visit and an office visit on the same day?
Yes, if the office visit is significant, separately identifiable, and medically necessary, and you report it with modifier 25 (CMS, 2026).

Does Medicare cover a routine physical exam?
No. CMS lists the routine physical as not covered, with the patient paying 100% out of pocket. The AWV and the Welcome to Medicare exam are the covered visit types (CMS, 2026).

Reference:

  1. Centers for Medicare & Medicaid Services (CMS). Transmittal 2575, Change Request 8107: Editing Update for Annual Wellness Visit (AWV), Pub. 100-04. October 26, 2012. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2575CP.pdf
  2. CMS Medicare Learning Network. Annual Wellness Visit. Page updated April 2026. https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits/annual-wellness-visit
  3. CMS Medicare Learning Network. Medicare Wellness Visits. Page updated April 2026. https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits
  4. U.S. Department of Justice, U.S. Attorney’s Office, Middle District of Pennsylvania. Penn State Health Agrees To Pay More Than Eleven Million Dollars Following Its Voluntary Disclosure Of Improper Billings Related To Medicare Annual Wellness Visit Services. February 7, 2024. https://www.justice.gov/usao-mdpa/pr/penn-state-health-agrees-pay-more-eleven-million-dollars-following-its-voluntary
  5. CMS. Fiscal Year 2025 Improper Payments Fact Sheet. January 15, 2026. https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-improper-payments-fact-sheet
  6. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Medicare and the Health Care Delivery System, Chapter 3, “Medicare payment operations and their role in identifying improper payments.” June 2026. https://www.medpac.gov/wp-content/uploads/2026/06/Jun26_Ch3_MedPAC_Report_To_Congress_SEC.pdf. The 10% Part B initial denial rate (2024) and the 68% documentation share (FY2025) are CMS data as reported in this chapter.

Modifier 25 in Dermatology: When You Can Bill the Visit and the Procedure on the Same Day

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A patient comes in for a rash check, you biopsy a suspicious spot, and the claim comes back paid for the biopsy only. The visit you spent real time on is written off. Or it gets paid, and an auditor later decides the chart never earned it.

When can you bill an office visit and a procedure on the same day?

You can bill both when the visit is a significant, separately identifiable service on top of the procedure’s built-in work. That is the CPT definition behind modifier 25, a two-digit add-on to the E/M (evaluation and management, or office visit) code (AAD Position Statement, 2019).

Medicare’s rule comes from the CMS NCCI Policy Manual (2026 edition). The decision to perform a minor procedure is already paid inside the procedure. A separate, unrelated E/M can still be billed with modifier 25, and the two services don’t need different diagnoses.

What makes a visit “significant and separately identifiable”?

It means you evaluated or managed something beyond deciding whether to do the procedure. The AAD says the chart must justify medical necessity and document the separate service (Dermatology World, March 2018).

Here is an illustrative example. A patient seen for ongoing psoriasis care who also needs a suspicious lesion biopsied has two distinct problems. A patient who arrives for a planned biopsy and nothing else does not.

Reviora’s practical test (our guidance, not an AAD or CMS rule): if the procedure hadn’t happened, would the visit still have been medically necessary? If yes, you likely have a separate service. Either way, document that work in its own section of the note so a reviewer doesn’t have to dig through the procedure report.

Does modifier 25 apply to every dermatology procedure?

No. It applies to minor procedures, meaning those with a 0- or 10-day global period. Examples include biopsies, shave removals, lesion destruction, simple excisions, repairs, and Mohs surgery (AAD, Dermatology World, March 2018). A global period is the window of pre- and post-procedure care already bundled into the procedure’s payment.

Major procedures, like flaps and grafts, carry 90-day global periods. A same-day E/M that leads to the decision to perform one takes modifier 57 instead (CMS NCCI Policy Manual, 2026).

Why are payers cutting and auditing modifier 25 claims?

Because dermatology’s visit-plus-procedure pattern makes the modifier an easy target. OIG’s 2005 audit (OEI-07-03-00470) found that 35% of Medicare-allowed claims using modifier 25 in 2002 did not meet program requirements, totaling $538 million in improper payments. That’s old data, so treat it as history, not a forecast.

Today’s pressure is mostly commercial. The AAD reports that UnitedHealthcare, Elevance Health, and Aetna have policies that reduce payment when modifier 25 is used (Dermatology World, October 2025). It also reported that Regence BCBS rescinded a policy that would have cut non-preventive E/M payment by 50% when billed with a 0- or 10-day global procedure (AAD Impact, 2026). That one is gone, but policies shift, so check each payer’s current rules.

How should a practice protect its modifier 25 revenue?

Here is Reviora’s practical checklist (our guidance, not a regulatory requirement). Audit your modifier 25 rate by provider before a payer does it for you. A high rate isn’t automatically wrong in a specialty that pairs visits with procedures, but every claim needs chart evidence behind it.

Before billing, ask three questions. Was a separate problem evaluated? Is it documented on its own? Does this payer’s policy accept it? Then track denials and reductions by payer, because the rules differ.

At Reviora Healthcare LLC, human specialists lead coding review and denial follow-up, with technology supporting them. We call that Expert-Led Technology. It runs through our Billing & Coding and Claims & Denials services, and our Dermatology RCM program.

Clients work under a Managed Outcomes Agreement (MOA), a written contractual performance agreement built on five benchmarks. If a benchmark is missed two consecutive months, the Benchmark Recovery Protocol (BRP) activates as the accountability mechanism. See how it works.

Want a second set of eyes on your modifier 25 claims? Book a 30-minute consult, or visit Get Started.

FAQ

Can you bill modifier 25 with a skin biopsy on the same day?
Yes, when the visit is significant and separately identifiable beyond the decision to biopsy. A visit made only to decide on or perform the biopsy isn’t billable separately (CMS NCCI Policy Manual, 2026).

Do you need a different diagnosis code to use modifier 25?
Not under Medicare’s NCCI policy, which states the E/M and minor procedure do not require different diagnoses. Commercial payers may set their own rules, so check each policy.

Can you use modifier 25 on a new patient visit?
Yes, the same rules apply. But NCCI says a patient being new to you isn’t enough on its own to justify a same-day E/M with a minor procedure. The separate service still has to be documented.

Do commercial insurers pay less when I use modifier 25?
Some do. The AAD named UnitedHealthcare, Elevance Health, and Aetna as payers with payment-reduction policies (Dermatology World, October 2025). Check your contracts and payer bulletins.

Reference

Group Therapy vs. Individual Session Coding: The Denial Risk Most Practices Miss

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When federal auditors sampled 100 psychotherapy services at one Nevada practice, only one met Medicare’s requirements. The HHS Office of Inspector General (OIG) estimated that at least $421,272, or 93% of what the practice was paid, was unallowable (OIG, A-09-19-03018, April 2020). The most common failure: 82 services had no documented psychotherapy time. If your group and individual sessions run through one note template, you carry the same kind of exposure, and it doesn’t expire when the claim pays.

Scope note: every source below is Medicare-focused. Commercial payers set their own rules, so check each contract.

How do group and individual psychotherapy differ for coding and documentation?

Individual psychotherapy codes are time-based, while group psychotherapy (CPT 90853) is a separate code family with its own documentation logic. For the time-based codes, one Medicare contractor’s guidance applies the CPT time rule: exact minutes must be in the record, nothing under 16 minutes is billable, and you select the code closest to the documented time (CGS Administrators, LCD L34353 Fact Sheet, 2021).

The risk starts when a practice runs both session types through one workflow. An individual session needs a defensible clock. A group session needs a record that proves what happened and who was there.

Where does a mixed group-and-individual workflow break?

At the seams: time stamps that can’t be reconciled, and notes stored apart from the claim. OIG’s audits didn’t isolate group-to-individual mix-ups, but they documented both failures such a mix-up would produce.

In the Nevada audit, one clinician’s records showed three individual sessions overlapping within the same hour. OIG concluded the times were likely inaccurate, since a provider can’t see three patients at once for individual therapy (OIG, 2020). Two group services also failed because the notes sat in handwritten records at an offsite location and never reached the billing system. The care may have happened. The proof didn’t travel.

What does a group note need to survive review?

It must be individualized for each patient, not cloned across the roster. OIG’s national review of 1998 Medicare claims found 50% of group psychotherapy services were inappropriate. Over half of those lacked elements such as treatment goals, progress, diagnosis, or session content, and some used “canned” language (OIG, OEI-03-99-00130, 2001).

That review is dated, but the contractor guidance asks for similar elements today. The 2021 fact sheet expects a clinical note for each encounter covering diagnosis, symptoms, functional status, treatment plan, progress, and the signed name and credentials of the person delivering the service (CGS, 2021).

What does a coding error cost after the claim is paid?

More than the denial. Once a provider has credible information of a potential overpayment, it must exercise reasonable diligence across a six-year lookback and return identified overpayments within 60 days (OIG, 2020, citing 42 CFR §§ 401.301–401.305). Officials at the audited practice told OIG that no one reviewed claims before submission or compared them to medical records (OIG, 2020).

The cheapest control is a pre-bill check: claim against note, time against code, group against individual. Reviora’s Billing & Coding and Claims & Denials teams are built on Expert-Led Technology: human specialists lead the review, and technology supports them. Our Behavioral Health RCM clients work under a Managed Outcomes Agreement (MOA), a written contractual performance agreement built on five benchmarks. A Benchmark Recovery Protocol (BRP) activates after two consecutive missed months. See how it works.

Want a second set of eyes on how your group and individual sessions are documented and coded? Book a 30-minute consult or visit Get Started.

FAQ

What is the minimum time to bill individual psychotherapy under Medicare?
Sixteen minutes. Psychotherapy shouldn’t be reported under 16 minutes, and exact times must be documented (CGS, 2021; OIG, 2020).

Can I bill a social or activity group as group psychotherapy?
Generally not for Medicare. Contractor guidance excludes recreational therapy and social interaction from psychotherapy codes (CGS, 2021). OIG found about 40% of inappropriate group services in its 2001 review were non-covered activity-type groups.

How long do I have to repay a Medicare overpayment I find?
Generally 60 days after you identify it, with a six-year lookback period for identification (OIG, 2020, citing 42 CFR §§ 401.301–401.305).

Can I use the same note for every patient in a group?
That’s high-risk. OIG flagged “canned” group notes in 2001, and contractor guidance expects encounter notes that reflect each patient’s diagnosis, progress, and plan (CGS, 2021).

Reference

  1. U.S. HHS Office of Inspector General. Grand Desert Psychiatric Services: Audit of Medicare Payments for Psychotherapy Services, Report A-09-19-03018. April 2020. https://oig.hhs.gov/oas/reports/region9/91903018.asp
  2. U.S. HHS Office of Inspector General. Medicare Part B Payments for Mental Health Services, Report OEI-03-99-00130. May 2001. Available at oig.hhs.gov (search the report number).
  3. CGS Administrators, LLC (Medicare Administrative Contractor). Outpatient Psychiatry & Psychology Services, LCD L34353 Fact Sheet. Revised May 26, 2021. https://www.cgsmedicare.com/pdf/psychotherapy_checklist.pdf

Denial Rate Benchmarks Across Specialties: Wound Care vs. Ortho vs. OB/GYN vs. Behavioral Health vs. Primary Care

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If your practice matches the typical single-specialty group, about 8 of every 100 claims come back denied on first submission (MGMA DataDive, 2023). Physicians who handle prior authorizations report 13 hours of physician and staff time a week on them (AMA Prior Authorization Physician Survey, 2025). The scarier part: most owners can’t say whether their own number is normal for their specialty, so a leak can run for months unnoticed.

What is a normal denial rate for a specialty practice?

Eight percent is the best-verified benchmark available. MGMA’s 2023 DataDive Practice Operations data set showed single-specialty groups had 8% of claims denied on first submission (the “initial denial rate”), unchanged from 2019.

Flat averages can hide drift. In a March 2024 MGMA Stat poll of 235 practices, 60% of leaders said denials had risen year over year, and only 11% said they had fallen.

Why isn’t there a clean Wound Care vs. Ortho vs. OB/GYN vs. Behavioral Health vs. Primary Care table?

We couldn’t find a public specialty-level denial table tied to a named dataset. If one sits inside a subscription product like MGMA DataDive, we haven’t seen it. The tables circulating online rarely cite a data set, so we won’t repeat them.

Definitions also differ. HFMA’s Claim Integrity Task Force defines the initial denial rate as each claim’s first denial divided by total claims submitted, reported by volume and by gross charges. It tracks denial write-offs separately (MAP Key AR-6).

KFF’s analysis of 2024 HealthCare.gov filings (March 2026) found insurers denied 19% of in-network claims. But that counts only claims ultimately denied, excluding those paid after resubmission. MGMA’s 8% counts first-submission denials. Same word, different measures.

KFF’s insurers also ranged from 3% to 36%, so any average without a payer breakdown tells you little.

What pushes wound care and orthopedic denials up?

Prior authorization (PA, a payer’s pre-approval), which reached traditional Medicare in 2026. Since January 1, CMS’s WISeR model has applied PA or pre-payment review in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington). It covers select services, including skin and tissue substitutes (wound care) and knee arthroscopy for osteoarthritis (orthopedics). Providers choose between submitting a request or accepting review before payment.

The AMA’s 2025 survey (1,000 physicians, administered December 2025, all screened to complete PAs in a typical week) found physicians averaging 40 PA requests weekly. Thirty-two percent said requests are often or always denied. It’s self-reported and covers all specialties, but WISeR shows which procedures regulators are watching.

What changes the picture for OB/GYN, behavioral health and primary care?

Each faces a different pressure. OB/GYN has a date: January 1, 2027. Per MGMA (August 2026), CPT deletes 17 maternity codes, including global codes 59400, 59510 and 59610 (single codes covering most of a pregnancy). It adds 12 organized by phase of care and moves prenatal and postpartum visits to E/M codes with a TH modifier. Every visit note must now stand alone as a billable encounter.

Behavioral health sits under parity rules, but enforcement is shifting. KFF’s March 2026 analysis notes the 2024 parity regulation required plans to evaluate certain claim-denial data, and that the administration has said it won’t enforce those requirements.

For primary care, we found no specialty-specific public denial data. MGMA’s March 2024 poll of practices generally listed insufficient documentation, eligibility and ID errors, untimely filing, and modifier 25 problems among leading causes of recent denials.

How should you benchmark your own practice?

Against yourself first, using HFMA’s definitions. Count each claim’s first denial, divide by total claims submitted, and repeat in gross charges. Split by payer and service line, and track write-offs separately. Use 8% as an anchor, not a verdict, because your payer mix may justify a different number.

At Reviora Healthcare, human specialists lead and technology supports them: Expert-Led Technology. Our Managed Outcomes Agreement is a written, contractual performance agreement built on five benchmarks. If benchmarks are missed two consecutive months, our Benchmark Recovery Protocol kicks in. See how claims and denial management works, or read about The Reviora Guarantee.

Want a second set of eyes on your numbers? Book a 30-minute consult, or head to Get Started.

FAQ

What is the average claim denial rate for medical practices?
MGMA’s 2023 DataDive Practice Operations data set put single-specialty groups at 8% of claims denied on first submission. Other published rates use different definitions and payer mixes, so compare like with like.

How do you calculate a claim denial rate?
Count only each claim’s first denial (excluding rebills) and divide by total claims submitted in the period. Then repeat using gross charges. That is the Claim Integrity Task Force method from HFMA.

Does prior authorization apply to traditional Medicare?
In six states, yes, for select services under CMS’s WISeR model, which began January 1, 2026. CMS says the model doesn’t change Medicare coverage or payment policy.

What is changing for OB/GYN billing in 2027?
On January 1, 2027, CPT maternity global codes 59400, 59510 and 59610 are deleted and replaced by phase-based codes, per MGMA (August 2026). CMS’s July 2026 proposed rule would also add optional Medicare G-codes. The final rule is expected around November 1, 2026.

References

Why OB/GYN Practices Wait So Long to Get Paid (and Why 2027 Raises the Stakes)

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Reviora Healthcare LLC | Guaranteed Revenue Partner

A patient who starts prenatal care with you this fall will deliver in 2027, after the billing code your practice has leaned on for years no longer exists. You’re delivering months of care today that many practices won’t invoice until after delivery, and the rules for billing it change mid-pregnancy. That’s earned cash sitting in limbo.

Why does OB/GYN billing take so long to get paid?

Because the global obstetric code folds most of a pregnancy into one billable service. The AMA describes it as a single code that effectively represents nine months of care. Bill it as one claim, and the payment clock starts late.

MGMA’s 2025 DataDive definitions use this exact scenario: a practice opens an account when a patient enters a prenatal program and doesn’t invoice until after delivery. That isn’t sloppy billing. It’s how the model works.

Does your Days in A/R number show the whole delay?

Not on its own. Days in A/R is the average time between billing a claim and getting paid, and MGMA’s definitions say a charge enters A/R only when the invoice is submitted. Months of prenatal work can sit outside the metric entirely. mgma

A healthy-looking A/R number can coexist with a stack of unbilled OB episodes, so track both.

Payers aren’t helping. In MGMA’s July 28, 2026 Stat poll, 32% of medical group leaders said days in A/R were higher than a year ago. Those reporting increases cited slower payment, initial denials, downcoding, records requests, and lengthy appeals. The poll drew 203 applicable responses across specialties, so treat it as a directional signal, not an OB/GYN benchmark.

Who pays for deliveries, and why does it matter?

Mostly commercial plans and Medicaid, and each sets its own rules. The CDC’s National Center for Health Statistics reports that private insurance covered 51.8% of 2024 deliveries and Medicaid 40.2%. MGMA notes that Medicare covers a limited share of maternity care, so how Medicaid and commercial payers adopt new coding may matter more than Medicare’s choices. cdcmgma

Payer billing and payment policies can vary, which means your timelines will too.

What changes on January 1, 2027?

The global codes disappear. The AMA’s CPT 2027 update deletes 17 maternity codes, adds 12, and revises six, with 59400, 59510, and 59610 among those deleted. Prenatal and postpartum visits will be reported per encounter using standard office-visit (E/M) codes.

That creates a documentation problem. MGMA’s Heather Signorelli, DO, notes that a light prenatal note carried no financial penalty under global billing, but each visit must now stand on its own as a billable encounter.

Medicare adds uncertainty. MGMA reports CMS is considering optional Medicare G-codes that would preserve a global payment option. That’s proposed, not final. The AMA expects CMS’s final rule in early November.

What should OB/GYN practices do before the cutoff?

Build a baseline now. MGMA recommends tracking days in A/R, clean claim rate, denial rate, net collection rate, and reimbursement per delivery by payer for the rest of 2026, so you can tell in March whether a dip is the transition or an older problem.

MGMA also advises counting patients due on or after January 1, getting each payer’s transition rules in writing, auditing prenatal documentation, and checking contracts that name deleted codes.

This is where specialist-led RCM earns its keep. Reviora runs on Expert-Led Technology: human specialists lead, and technology supports them. For OB/GYN groups, the areas to watch are claims and denials, A/R recovery, and billing and coding. We approach them through our OB/GYN RCM work, part of our broader specialty RCM services.

Our Managed Outcomes Agreement is a written, contractual performance agreement built on five benchmarks. A Benchmark Recovery Protocol activates after two consecutive missed months. See The Reviora Guarantee for how it works.

Want a second set of eyes on your OB baseline before January? Book a 30-minute Free Consultation, or visit Get Started.

FAQ

What is the global OB package in medical billing?
It’s a single CPT code, such as 59400, that bundles routine prenatal care, delivery, and postpartum care into one claim. The AMA says it effectively represents nine months of care as a single service.

Is CPT 59400 going away in 2027?
Yes. The AMA is deleting 59400 and 16 other maternity codes effective Jan. 1, 2027, replacing them with per-visit E/M codes plus new labor management and delivery codes. Any Medicare G-code option is still proposed, not final.

How do I bill a pregnancy that spans 2026 and 2027?
MGMA’s summary of CPT guidance says 2026 prenatal services stay under 2026 rules while 2027 encounters move to E/M reporting, and payers may add their own requirements. Get each payer’s guidance in writing. The AMA also publishes a transition-date FAQ.

What are good days in A/R for an OB/GYN practice?
Rather than chase a generic target, compare against MGMA DataDive peer data and your own pre-2027 baseline. Remember that uninvoiced OB charges don’t count toward the metric until they’re billed.

This article is educational and isn’t coding, billing, or legal advice. Confirm requirements with your payers and compliance counsel.

Reference

Bundled Payment Billing for Orthopedic: Avoiding the Days-in-AR Trap

Posted on by Reviora Healthcare LLC in Newsletter

Reviora Healthcare LLC | Guaranteed Revenue Partner

A surgeon finishes a clean knee replacement. Ninety days later, the hospital is closing out the episode, your staff is still chasing an authorization from week one, and your AR report shows claims aging that nobody flagged. That’s the days-in-AR trap: not one big mistake, but small delays stacking up inside a payment model with no slack. Every extra week is cash you already earned sitting in someone else’s queue.

What Is Bundled Payment Billing in Orthopedics?

Bundled payment sets one target price for an entire episode of care, the procedure plus related services through 90 days after discharge, instead of paying each piece separately. CMS tested this on hip, knee, and ankle replacements through its Comprehensive Care for Joint Replacement (CJR) Model, which ran in 34 metropolitan areas until December 31, 2024. CMS’s final evaluation, published in September 2026, found the model generated $180 million in Medicare savings while preserving care quality. CMSCenters for Medicare & Medicaid Services

That result is why the model is going national. CJR-X will be mandatory nationwide and begin January 1, 2028. If your surgeons do joint replacements, see how we handle orthopedic revenue cycle management.

Who Carries the Risk, and Why Does It Reach Your Billing Office?

Under CJR-X, the hospital carries the financial risk, not the practice. Participating acute care hospitals are measured against a target price covering the procedure, the stay, post-discharge therapy, and follow-up visits. CMS

Your practice isn’t the party repaid or repaying, but expect hospital partners to demand cleaner documentation, faster authorizations, and tighter coordination from surgeons’ offices. That pressure lands on your billing team. If your process was built for one claim at a time, the added coordination is where days start slipping.

Why Does Days in AR Creep Up Under Episode-Based Payment?

Days in AR creeps up because delays compound: one late step pushes every step after it. Days in AR, per HFMA’s methodology, is net accounts receivable divided by average daily net patient service revenue, in plain terms, how long the average dollar waits to be collected. TechTarget

Three delays do most of the damage in ortho:

  • An authorization that clears after the surgery date instead of before it.
  • Documentation gaps that stall a claim until someone notices.
  • A denial worked at day 45 instead of day 5.

None looks serious alone. Together they age every dollar behind them, which is why a dedicated AR recovery process works claims by age instead of waiting for month-end.

How Much Does Prior Authorization Add to the Delay?

Prior authorization is usually the first link in the chain, and when it’s late, everything downstream is late. In AMA’s May 2026 survey release, 95% of physicians said prior authorization delays access to necessary care, and 79% said patients abandon treatment because of authorization challenges. American Medical Association

For a scheduled joint replacement, an authorization still pending near the surgery date raises the risk of a denial after the fact. Fixing it upstream, verifying and documenting before the case is booked, is cheaper than appealing after. Our claims and denial management team works this way.

What Does an Expert-Led Fix Look Like?

It starts with people who own the outcome, backed by a written commitment. Reviora runs on Expert-Led Technology: credentialed RCM specialists lead every account, and technology supports them by flagging stalled claims early.

Our Managed Outcomes Agreement is a written contractual performance agreement built around five benchmarks, days in AR among them. If performance misses for two consecutive months, the Benchmark Recovery Protocol activates: an accountability mechanism, not a sales conversation. You can see how the benchmarks work before you talk to anyone.

CJR-X is about 15 months out. The practices that come through it well will be the ones that tightened authorization and AR follow-up before hospitals started asking. If you want an outside read on your current process, book a 30-minute consult. We’ll look at your AR aging and tell you plainly where the exposure is. Ready to move? Get started here.

FAQ

What is a bundled payment in orthopedic surgery?
It’s one target price for an entire episode of care, covering the procedure and related services through 90 days after discharge, instead of separate payments for each service.

Is the CMS joint replacement bundled payment mandatory?
For the hospitals it covers, yes. CJR ended December 31, 2024, and its expansion, CJR-X, is scheduled to be mandatory nationwide from January 1, 2028.

How many days in AR is too many for an orthopedic practice?
No single figure fits every practice, and many published specialty benchmarks can’t be traced to a named source. Start with your own trailing 12-month days in AR, then look at how much of your AR is sitting in the oldest buckets.

How can an orthopedic practice reduce days in AR?
Clear authorizations before the surgery date, work denials in days rather than weeks, and review AR by age every week. A written performance agreement with your billing partner keeps someone accountable for the number.

Reference

Telehealth Behavioral Health Billing: Payer-by-Payer Reimbursement Differences

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Reviora Healthcare LLC | Guaranteed Revenue Partner

Here’s the number that should worry you: Medicare Advantage insurers denied prior authorization requests at rates ranging from 4.2% to 12.8% depending on the insurer in 2024 (KFF, January 2026). Same benefit, same rules on paper, a three-fold spread in outcome. If your billing team treats every payer’s telehealth behavioral health claim the same way, you’re leaving reimbursement on the table with every claim you send to the “wrong” payer the “wrong” way.

Does Medicare Pay Telehealth Behavioral Health Claims the Same as In-Person Visits?

On rate, largely yes. On access, it’s more complicated than most practices assume. CMS has made audio-only delivery and the removal of geographic originating-site restrictions permanent for behavioral and mental telehealth (Telehealth.HHS.gov, Telehealth Policy Updates, accessed 2026). Where it gets murky is the in-person visit requirement tied to ongoing behavioral telehealth care — a provision that has been extended, delayed, and modified by Congress multiple times since 2023 (CMS Telehealth FAQ, updated February 2026; American Psychiatric Association, January 2026). Because this rule keeps moving, verify the current requirement against CMS’s own FAQ before you set a billing policy around it.

Why Does Prior Authorization Burden Vary So Much Between Insurers?

Because insurers apply it at very different rates, and behavioral health services are disproportionately subject to it. The 2024 AMA Prior Authorization Physician Survey of 1,000 physicians found that roughly 93–94% report PA delays patients’ access to necessary care, and about 3 in 10 physicians say authorizations are often or always denied outright (American Medical Association, 2024). Layer in the KFF finding that request volume per enrollee ranged from 0.6 to 3.0 across major Medicare Advantage insurers (KFF, 2026), and it’s clear your exposure is shaped as much by your payer mix as by your documentation quality.

Are Commercial Payers Required to Pay Telehealth at the Same Rate as In-Person Care?

Only in about half the country, and it depends entirely on the state your patient sits in. As of Fall 2025, 44 states plus DC, Puerto Rico, and the Virgin Islands have laws addressing private payer telehealth reimbursement — but only 24 states plus Puerto Rico have an explicit payment parity requirement (Center for Connected Health Policy, State Telehealth Laws and Reimbursement Policies, Fall 2025). The rest guarantee coverage only, meaning a payer can legally reimburse a video visit at less than an in-person one. A multi-state telehealth practice is running dozens of different reimbursement rulebooks at once, not one.

Does Medicaid Cover Telehealth Behavioral Health the Same Way in Every State?

No. All 50 states and DC reimburse some telehealth under Medicaid, but which modalities count — including audio-only — and which services qualify is set state by state, not federally (CCHP, Fall 2025). A behavioral health practice billing Medicaid across two or three states is effectively running two or three separate Medicaid billing processes.

What Does This Mean for Your Denial Rate?

The best available industry-wide benchmark — MGMA’s DataDive Practice Operations data set — puts the aggregate first-submission denial rate at 8%, flat since 2019 (MGMA, 2023 data, published 2024). No primary source currently publishes a reliable, behavioral-health-specific breakout of that number, so be skeptical of anyone quoting you a precise behavioral health denial percentage — ask where it actually comes from. What the verified data does show clearly is that electronic prior authorization adoption industry-wide sits at just 35% (CAQH Index, 2024), which means a large share of behavioral health authorizations are still resolved manually — by phone, fax, or portal — and manual processes are where payer-specific rules get lost.

What This Means for Your Practice

Payer variation here isn’t a footnote — it’s the operating environment. The practices absorbing the least revenue leakage build payer-specific playbooks instead of one generic telehealth billing workflow, and track authorization and in-person-visit timelines per patient, per payer, rather than relying on memory or spreadsheets.

This is where Reviora’s Expert-Led Technology model earns its keep: credentialed billing specialists who track payer-specific behavioral health rules directly, with technology supporting — not replacing — that judgment. Every Reviora engagement is governed by a Managed Outcomes Agreement, a written contractual performance agreement covering five defined benchmarks, backed by a Benchmark Recovery Protocol that activates automatically if performance slips for two consecutive months. It’s accountability you can hold us to.

If you want a second set of eyes on how your practice’s payer mix is actually performing, Book a Free 30-minute Consultation. Explore our Behavioral Health RCM services, our Claims & Denials Management sub-service, or see how the Reviora Guarantee works.

FAQ

Does Medicare pay the same for telehealth behavioral health visits as in-person visits?
Largely yes on rate, but the in-person visit requirement tied to ongoing telehealth care has changed repeatedly since 2023 — verify the current rule against CMS’s Telehealth FAQ before billing (CMS, updated February 2026).

Do all states require insurance companies to pay telehealth at the same rate as in-person visits?
No. Only 24 states plus Puerto Rico currently require payment parity; the rest with telehealth laws guarantee coverage only, not equal pay (CCHP, Fall 2025).

Why does prior authorization burden vary so much between insurance companies?
Insurers apply prior authorization at very different volumes and denial rates — in 2024, Medicare Advantage denial rates ranged from 4.2% to 12.8% by insurer (KFF, 2026), and 93–94% of physicians report it delays patient care industry-wide (AMA, 2024).

Does Medicaid cover telehealth therapy the same way in every state?
No. Every state Medicaid program covers some telehealth, but eligible modalities — including audio-only — and covered services differ state by state (CCHP, Fall 2025).

Reference

Postpartum and Antepartum Coding: Why OB/GYN Practices Miss First-Pass Resolution Targets

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Reviora Healthcare LLC | Guaranteed Revenue Partner

A clean delivery with no complications can still turn into a denied claim, an unpaid postpartum visit, or a payment held for months — not because anything went wrong clinically, but because the billing never matched how the pregnancy was actually managed. For a practice running on thin margins, that gap between “the patient did fine” and “the claim got paid” is where real revenue quietly disappears.

Why does OB/GYN coding miss first-pass resolution more than other specialties?

OB/GYN coding fails first-pass resolution because it currently runs on a single bundled code covering nine-plus months of care, while most billing systems and workflows are built around single-encounter claims. The global obstetric codes (59400, 59510, 59610, 59618) combine antepartum care, delivery, and postpartum care into one code — a model the American Medical Association itself has now confirmed is outdated. In 2026, the AMA announced it is retiring this global package entirely, replacing it with four separately reportable phases of care (antepartum, labor management, delivery, postpartum), effective January 1, 2027 — specifically because the bundled model no longer reflects modern, team-based obstetric care.

What exactly goes wrong in antepartum and postpartum claims under the current model?

The most common failure is billing the global code when the practice didn’t actually provide all three bundled components. If a patient transfers care mid-pregnancy, changes insurance, or is seen for fewer prenatal visits than a payer requires, the antepartum, delivery, and postpartum portions typically need to be billed as separate, itemized codes instead. Practices that default to the global code out of habit — instead of tracking visit counts and care continuity in real time — are billing for a package they didn’t fully deliver, and that mismatch is exactly the kind of gap AMA cited as a reason for the 2027 overhaul.

What does a missed first-pass resolution target actually cost?

It costs more than the claim itself — it costs the rework cycle. MGMA’s DataDive Practice Operations data set has shown single-specialty first-submission denial rates holding around 8% since 2019, a rate that hasn’t moved, meaning the problem isn’t new and most practices haven’t fixed it. Every reworked claim also carries a hidden administrative tax: the 2024 CAQH Index estimates that shifting the industry’s remaining manual administrative transactions — including claims and prior authorization work — to automated processes represents a $20 billion annual opportunity, money currently spent on staff re-touching work that should have gone through clean the first time.

Why does the 2027 change make fixing this now more urgent, not less?

Because practices that are already sloppy about tracking visit counts and care-phase documentation under the old bundled model will struggle even more under a system that requires reporting each phase separately. The AMA’s own transition guidance calls for physicians, coders, and EHR vendors to prepare in advance of the 2027 effective date. A practice that gets antepartum-versus-postpartum documentation discipline right now is building the exact muscle the new coding structure will require — not just protecting today’s cash flow.

Why doesn’t automation alone solve this?

Software can flag a missing modifier. It can’t tell you whether the OB saw the patient enough times, in the right window, to justify one billing approach over another — that judgment call requires someone who understands both the coding rules and the clinical timeline. This is why Reviora’s model is Expert-Led Technology: credentialed specialists review the actual care pattern behind each pregnancy before the claim goes out, and technology supports that review rather than replacing it.

How does a practice actually hold a vendor accountable for this?

Through a written, contractual performance agreement rather than a verbal promise. Reviora structures every engagement around a Managed Outcomes Agreement (MOA) — five specific benchmarks the relationship is measured against — backed by a Benchmark Recovery Protocol (BRP) that activates automatically if performance misses target for two consecutive months. That’s the accountability structure administrators should be asking every RCM vendor for, whether or not they ever work with Reviora.

If your OB/GYN practice is seeing global maternity claims bounce back for correction — or you’re wondering how the 2027 coding changes will affect your workflow — a 30-minute conversation can usually surface where the pattern is coming from. Book a consultation to walk through your current first-pass numbers.

Explore further:

FAQ

Why do OB/GYN claims get denied even after a normal delivery?
Most often because the global maternity code was billed when the full three-part bundled package (antepartum, delivery, postpartum) wasn’t actually delivered by one provider or practice — a mid-pregnancy transfer or insurance change is enough to break it.

What is the global OB package in medical billing, and is it changing?
It’s currently a single code (59400, 59510, 59610, or 59618) bundling antepartum visits, delivery, and postpartum care into one reimbursement. The AMA is retiring this model effective January 1, 2027, replacing it with separate reporting for antepartum care, labor management, delivery, and postpartum care.

How many antepartum visits are required to bill the global maternity code?
Payer policies vary, but a commonly applied threshold is four or more prenatal visits before delivery; fewer visits typically require itemized, non-global billing instead.

What’s a realistic denial-rate benchmark for an OB/GYN practice to track against?
MGMA’s DataDive Practice Operations data has held single-specialty first-submission denial rates around 8% since 2019 — a useful national reference point, though your own payer mix and documentation discipline will move you above or below it.

Reference

Chronic Care Management Billing: The Compliance Rules Practices Overlook

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Reviora Healthcare LLC | Guaranteed Revenue Partner

Medicare has already clawed back $1.9 million from 50,192 chronic care management claims — and that was just one audit cycle. In 2026, OIG opened a fresh, multi-year review of CCM billing specifically targeting whether your patients even qualify. If your practice runs CCM and nobody’s double-checking eligibility documentation, you’re not managing a revenue stream — you’re carrying an open liability.

What does Medicare actually require to bill CCM?

CMS pays CCM under CPT 99490 for at least 20 minutes of clinical staff time per calendar month, directed by a physician or qualified practitioner, for a patient with two or more chronic conditions expected to last 12+ months or until death. The requirements are specific: two or more chronic conditions expected to last at least 12 months or until the patient’s death, conditions that place the patient at significant risk of death, acute exacerbation, or functional decline, and a comprehensive care plan that’s established, implemented, revised, or monitored (CMS, MLN Booklet, 2025). The time has to come from an eligible initiating visit — an E/M encounter, Annual Wellness Visit, or Initial Preventive Physical Exam — and the patient’s problems, medications, and allergies must live in certified EHR technology accessible to every staff member counting toward that 20 minutes (CMS, Chronic Care Management Checklist, November 2023). Miss any one piece, and the claim isn’t compliant, even if the time was genuinely spent.

Why is CCM one of Medicare’s highest-risk billing categories right now?

Because the error pattern is already documented at scale. In its 2021 audit of 2017–2018 claims, OIG found $1.9 million in overpayments across 50,192 claims, with 38,447 of those claims resulting from providers billing noncomplex or complex CCM more than once for the same beneficiary in the same service period, and another 10,882 claims stemming from CCM billed alongside overlapping care management services for the same patient (HHS-OIG, Report A-07-19-05122, August 2021). Beneficiaries themselves were overcharged up to $540,680 in cost-sharing as a direct result (HHS-OIG, Report A-07-19-05122, August 2021). These weren’t fraud rings. They were duplicate billing and overlapping-code errors — the kind that happen when nobody’s cross-checking the calendar month before submission.

What triggered OIG’s new 2026 audit, and why does it matter to you?

Because Medicare Part B payments for CCM services increased substantially from calendar year 2019 through 2024, and OIG is now reviewing whether the beneficiaries billed for CCM actually meet the multiple-chronic-conditions requirement (HHS-OIG Work Plan, announced March 16, 2026). This audit is scheduled to run through an estimated FY2028 completion. Translation: eligibility documentation — not just time logs — is the current federal scrutiny target. If your care plans don’t clearly show two qualifying conditions with the required risk profile, that’s the exact gap examiners are now built to find.

What internal controls actually prevent these errors?

A hard rule that only one practitioner can bill CCM for a patient per calendar month, checked before every submission — not after. CMS’s own provider checklist requires informing patients that only one practitioner can furnish and bill CCM during a calendar month, and that consent must be documented in the medical record (CMS, Chronic Care Management Checklist, November 2023). A minute-by-minute time log tied to named staff, not a monthly estimate reconstructed after the fact. And a claims edit process that flags a second CCM claim for the same beneficiary before it goes out the door — the exact failure CMS itself admitted it lacked during the audited period (HHS-OIG, Report A-07-19-05122, August 2021).

How Reviora keeps CCM billing audit-ready

This is where Expert-Led Technology earns its name — human specialists, not software alone, reviewing eligibility and time documentation before every CCM claim leaves the building. Our Medical Billing & Coding and Claims Submission & Denial Management teams build the duplicate-billing and eligibility checks directly into the pre-submission workflow, and every engagement runs under our Managed Outcomes Agreement — a written performance framework with the Benchmark Recovery Protocol activating automatically if standards slip two months running. If CCM sits inside a broader chronic-disease population, our Primary Care RCM team applies the same discipline across every recurring code, not just CCM.

If your CCM program hasn’t had a documentation review since before March 2026, that’s worth a conversation. Book a 30-minute consultation and we’ll walk through where your current process stands against what OIG is now actively auditing.

FAQ

Can CCM be billed without the patient signing a consent form?
Consent must be documented in the patient’s record, though it can be verbal or written; what matters to auditors is that it’s documented, not the format (CMS, Chronic Care Management Checklist, November 2023).

How many minutes per month does CCM actually require?
At least 20 minutes of clinical staff time in a single calendar month for CPT 99490 — time doesn’t carry over between months (CMS, MLN Booklet, 2025).

Can two different providers bill CCM for the same patient in the same month?
No. Only one practitioner may furnish and bill CCM services per beneficiary per calendar month, and billing for overlapping care management is one of the two largest error categories OIG identified in its audit (HHS-OIG, Report A-07-19-05122, August 2021).

Why is OIG auditing chronic care management in 2026?
Because Medicare Part B CCM payments grew substantially from 2019 through 2024, prompting a new multi-year review of whether billed patients meet the multiple-chronic-conditions eligibility requirement (HHS-OIG Work Plan, announced March 16, 2026).

Reference