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KLA Healthcare Consultants, Bartlett, TN (2025)

10/22/2025

🌟 2026 Quality Measures: What’s Changing & Who’s Ready 🌟

CMS’s 2026 Quality Payment Program (QPP) proposed rule may not yet be finalized—thank you, government shutdown—but it’s already shaping how we’ll measure and reward “quality” across healthcare.

📘 CMS summary (official overview):
https://mdinteractive.com/mips-blog/whats-new-2026-qpp-proposed-rule-key-updates-mips-and-aco-participants
Here’s the short version of what’s ahead ⬇️
✅ MIPS stays at 75 points – no major scoring shakeup, but smarter reporting and measure validation will matter more than ever.
✅ New Improvement Activities (IAs) emphasize AI safety, cognitive impairment screening, and oral health integration.
✅ Interoperability expands with new requirements for security risk management and data exchange via TEFCA.
✅ ACO changes aim for more flexible attribution and equity in value-based care participation.

👉 Translation: 2026 will reward practices that are data-ready, prevention-minded, and connected across care teams.

🏥 Medicare Advantage Plans: How They’re Adapting for 2026
(alphabetically listed for easy reference)
Aetna
Aetna reports that 81% of members are now in 4★ or higher plans, emphasizing continuity of care and medication adherence. Expect enhanced alignment with CMS Star measures in 2026.
🔗 https://news.aetna.com/2026-medicare-advantage-star-ratings/

Anthem / Blue Cross Blue Shield (Elevance Health)
Rolling out state-specific 2026 provider manuals and CAHPS/HEDIS weighting updates that mirror CMS’s equity-driven quality model.
📋 Copy/paste to learn more: https://www.elevancehealth.com/providers

Cigna Healthcare
Their updated Cigna Care Designation (CCD) criteria now reward only the top 34% of groups for both quality and cost efficiency. Practices below that cut-off may lose their CCD status.
📘 https://static.cigna.com/assets/chcp/resourceLibrary/medicalResourcesList/medicalPlansAndProducts.html
(See also: https://cignaforhcp.cigna.com/app/login)

Humana
Focus areas: medication adherence, preventive screenings, and a tighter feedback loop for Stars scoring in 2026. Humana continues to pair quality incentives with wellness engagement.
📎 Copy/paste: https://press.humana.com/news/news-details/2026-star-ratings/

UnitedHealthcare
2026 MA Quick Reference Guide highlights the push toward quality-first network design and CMS Stars alignment. Expect closer data reviews for chronic condition management.
📄 Copy/paste: https://www.uhcprovider.com/

🧭 What You Can Do Now
1️⃣ Review your 2023–2024 performance data (these years set the stage for 2026) WITH YOUR insurance company’s Provider Relations Representative. Schedule this now.
2️⃣ Audit your quality and interoperability documentation now—CMS expects a clean chain of evidence.
3️⃣ Stay alert for final rule updates once the government reopens—CMS will move quickly.

10/07/2025

🔍 Top OIG Audit Targets for 2026 — and How Healthcare Organizations Can Stay One Step Ahead

(with a dash of humor — because compliance deserves a smile too)

Let’s face it — the OIG doesn’t exactly send out “You Pass!” postcards. But if you want to avoid surprise audit headaches in 2026, here are the areas they’re most likely to spotlight. Cue ominous audit music.

1️⃣ Managed Care & Risk Adjustment (Medicare Advantage / Medicaid Managed Care)
Because nothing says “fun” like an audit of diagnosis codes and risk scores.
Why they’ll dig here:
OIG plans audits of diagnosis codes submitted for risk adjustment, especially those lacking supporting documentation or face-to-face encounters.
They’re also watching for enrollment manipulation — enrolling people without consent or “cherry-picking” healthier members.
Examples / red flags:
• MA plan submits high-risk codes without solid documentation
• Agents earning bonuses for “selective” enrollments
• Claims still processed after member disenrollment

Tip: Audit your risk adjustment data, confirm coding accuracy, and document every encounter.
📎 Source: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp

2️⃣ Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Because yes — even your DME can end up on the OIG’s naughty list.
Why they’ll dig here:
OIG continues to focus on fraud, waste, and abuse within DMEPOS, especially around new billing schemes, accessories, and delivery verification.
Examples / red flags:
• Supplying scooters or oxygen concentrators with flimsy documentation
• Billing for “upgrades” not ordered by the physician
• Phantom suppliers or duplicate claims

Tip: Verify LCD requirements, confirm medical necessity, and keep supply-chain records tight.
📎 Source: https://oig.hhs.gov/reports-and-publications/workplan/active-item-table.asp

3️⃣ Home Health & Skilled Services
Because “home sweet home” doesn’t mean “audit free.”
Why they’ll dig here:
Recent OIG audits found unsupported billing and missing documentation in home health agencies. Expect scrutiny over skilled-need qualifications, plans of care, and remote patient monitoring claims.
Examples / red flags:
• Billing skilled therapy with no clear necessity
• Plans of care missing signatures or mismatched visits
• Remote monitoring data never reviewed or integrated
Tip: Perform internal audits, review plans of care regularly, and ensure real-time documentation.
📎 Source: https://oig.hhs.gov/reports/all/2025/medicare-home-health-agency-provider-compliance-audit-hrs-home-health/

4️⃣ Grants, Contracts & Public Health Programs
Because the OIG isn’t just about claims — it’s about every federal dollar.
Why they’ll dig here:
OIG’s 2025–2030 Strategic Plan highlights grant and contract oversight to prevent waste and mismanagement. Public health grants, pandemic relief funds, and subcontractor compliance will all be examined closely.
Examples / red flags:
• Deliverables that don’t match performance reports
• Charging the same expense to multiple grants
• Weak oversight of subcontractors or consultants

Tip: Segment grant accounting, tighten controls, and audit subrecipients early.
📎 Source: https://oig.hhs.gov/about-oig/strategic-plan/

5️⃣ Nursing Facilities & Long-Term Care
Because the OIG has a soft spot for residents — and a hard line on compliance failures.
Why they’ll dig here:
Expect continued focus on psychotropic drug use, staffing levels, and resident safety.
OIG recently released Industry Segment–Specific Compliance Program Guidance (ICPG) for skilled nursing facilities — and it’s a must-read.
Examples / red flags:
• Antipsychotic drugs without clear diagnosis or consent
• Inadequate staffing ratios or missing shift coverage
• Failure to report safety or quality metrics

Tip: Adopt ICPG guidance, review prescribing trends, and strengthen your QAPI program.
📎 Source: https://oig.hhs.gov/reports-and-publications/workplan/
📎 Budget report:https://www.hhs.gov/sites/default/files/fy-2026-oig-cj.pdf

🎯 Why 2026 Will Be Tougher (and a little less funny)
• The OIG’s FY 2026 budget request emphasizes stronger Medicare & Medicaid oversight.
• Expect more use of data analytics and AI to detect anomalies.
• Priority areas: Managed Care, Nursing Homes, and Federal Grants.
📎 Source:https://www.hhs.gov/sites/default/files/fy-2026-oig-cj.pdf

⚠️ Compliance Caveats & Fine Print
This post is for educational purposes only and not legal or regulatory advice.
Always consult your compliance, audit, or legal counsel before making operational changes.
The OIG’s Work Plan is updated frequently — check the latest version here:
👉 https://oig.hhs.gov/reports-and-publications/workplan/

💬 Compliance humor of the day:
“If you think nobody’s watching, remember — the OIG has better data analytics than Santa Claus.” 🎅📊

10/01/2025

⏸️🇺🇸 Government Shutdown: What it likely means for medical practices

We know today’s news is stressful. Here’s our best current read (not authoritative advice) on what providers should expect:

✅ Will we be paid for services?
Yes—Medicare claims are still being processed and paid. CMS’ official plan keeps Medicare running during a lapse, and MACs confirm operations continue. Oversight and response times may slow, but the payment pipeline remains open.

🤳 Telehealth & Hospital-at-Home
Some pandemic-era flexibilities expired 9/30. CMS/MACs are temporarily holding certain telehealth claims (≈10 business days) in case Congress restores them. You can submit, but payment may wait until the hold lifts or policy is renewed.

🧾 Medicaid/CHIP
Federal funding is in place for Q1 FY2026, so states should keep paying providers (administrative speed may vary).

🩺 Credentialing/Enrollment (PECOS)
Expect delays (not a freeze) for new enrollments and revalidations due to limited staffing.

💾 EDI & portal changes
Routine claims/ERA/eligibility transactions continue. New EDI setups or changes (submitter IDs, trading partner updates) may take longer.

📬 Appeals
Delays are likely across contractor and ALJ levels. Assume standard filing deadlines still apply unless agencies announce otherwise.

🙏 Bottom line
For most in-person services, keep seeing patients and billing as usual. Build some cash-flow cushion for possible slowdowns in special areas (telehealth, new enrollments, appeal responses).

🧷 Save these official resources (copy/paste):
CMS contingency (Medicare continues):
https://www.hhs.gov/about/budget/fy-2026-cms-contingency-staffing-plan/index.html
MAC update (claims continue; telehealth claim holds):
https://medicare.fcso.com/learning-center/update-medicare-operations-telehealth-claims-processing-and-medicare-administrative
CMS Telehealth page:
https://www.cms.gov/medicare/coverage/telehealth
APTA shutdown FAQ (provider-facing summary):
https://www.apta.org/article/2025/09/25/shutdown-faqs

⚠️ Disclaimer: This is our best prediction as of Oct 1, 2025, from public CMS/HHS posts and MAC notices. It isn’t legal, billing, or financial advice, and may change with new guidance or legislation.

09/23/2025

🤖 AI, Digital Medicine & Medicare: What’s New for October 2025

Healthcare tech isn’t slowing down—and neither are the codes! Starting this fall, Medicare is updating how it recognizes AI tools, digital devices, and remote monitoring services. That means new ways for practices to get paid for the digital work they’re already doing.

Here’s what’s changing:

Digital Therapeutics Get Codes 🧠 – New HCPCS G-codes support FDA-cleared devices for conditions like ADHD, sleep disturbance, and GI disorders. They must be used under clinician supervision, but yes—Medicare is starting to pay for “prescribable apps.”

Remote Monitoring Refinements 📊 – Updates to RPM (blood pressure cuffs, glucose monitors, etc.) and RTM (digital tools for pain, respiratory, musculoskeletal care). Expect:

New codes for shorter monitoring periods (2–15 days).

Tweaks to device supply codes with new payment rates (e.g., $47.06 for RPM device supply vs. $43.02 before).

Adjustments in RTM device supply codes (a little dip—$39.77 vs. $43.02).

AI & SaaS in the Spotlight 💻 – CMS wants your input! Right now, most software and AI tools are tucked inside “practice expense” buckets, which undervalues them. CMS is actively exploring whether AI should have its own codes and payment models. Translation: keep an eye out—this area is wide open for change.

Why it matters for practices:

These updates expand billable services in primary care, behavioral health, and chronic disease management.

Payment rates are shifting—some up, some down—so it’s worth reviewing which codes you already use.

CMS is asking for real-world feedback from clinics, vendors, and professional groups. If your practice relies on digital health, your voice could help shape future payment rules.

What to do now:
✅ Audit your digital tools (RPM cuffs, sleep apps, AI assistants).
✅ Double-check documentation (time, modality, days monitored, patient consent).
✅ Train staff on the new CPT/HCPCS codes going live October 1.
✅ Consider submitting feedback to CMS if AI/digital health is central to your practice.

👉 At KLA Healthcare, we’ll keep breaking down the fine print so you can focus on patient care (and still get paid for the digital side of medicine).

🌿 Sage advice: Technology doesn’t replace the provider—it amplifies your reach. Stay curious, stay compliant, and let the codes work for you.

09/16/2025

Telehealth After Oct 1: What Urban Providers Need to Know (with a phone-call twist) 📞💻

The big picture (MidSouth Edition) 🗺️
Without new action from Congress, key Medicare telehealth flexibilities end after September 30, 2025. That means the “patient at home anywhere” rule sunsets and the old Medicare rules return.

Urban providers can still deliver telehealth, but your Medicare patient generally must be at an approved “originating site” in a qualifying rural/HPSA location (think clinic, hospital, physician office, CAH—not the living room) unless a permanent exception applies.

Behavioral health from home keeps special protections. ⚖️ (Congress could still step in—watch this space.)

Modality matters 🎥📱
Video is the default for Medicare telehealth. Audio-only can still be used for certain services (notably behavioral health when a patient can’t or won’t use video). Place of service codes 02 (not at home) and 10 (at home) continue to apply.

Facility fee 💲
If the patient is at an originating site, that site may bill Q3014 (originating site fee). 2025 national payment: about $31.01. (Locality adjustments still apply.)

Not telehealth—but still payable: Medicare pays for certain telephone calls ☎️

These are “communication technology–based services” (CTBS), not telehealth visits. Use them when criteria are met (established patient, not related to an E/M in the prior 7 days, and not leading to one within 24 hours/soonest available).

• 98016 — “Virtual check-in” by a physician/other QHP, 5–10 min of medical discussion. National payment ≈ $15.85.

• 98966 — Non-physician/QHP telephone A/M, 5–10 min. National payment ≈ mid-$15s.

• 98967 — Non-physician/QHP telephone A/M, 11–20 min. National payment ≈ high-$20s.

• 98968 — Non-physician/QHP telephone A/M, 21–30 min. National payment ≈ low-$40s.

(Exact dollars vary by locality; check your MAC or the MPFS Look-Up. These phone calls are not billed as “telehealth,” so don’t add telehealth modifiers. ✅)

Urban provider checklist after Oct 1 🧾

• Confirm the patient’s location qualifies (or use an approved originating site partner).

• Use POS 02/10 correctly and keep audio-only limited to what’s allowed.
• For quick issues, consider 98016/98966–98968 instead of trying to force a telehealth visit.
• For originating sites, remember Q3014.

• Keep an eye on Congress—policy could change again fast.

Sage wisdom 🌿: Measure twice, code once…document thrice. Peaceful practices = fewer denials. ✌️

Without new action from Congress, key Medicare telehealth flexibilities end after September 30, 2025. That means the “patient at home anywhere” rule sunsets and the old Medicare rules return. ,,

09/13/2025

🚨 Heads up, providers! 🚨

Starting October 1, 2025, Cigna will launch policy R49 (“Evaluation & Management Coding Accuracy”) that lets them automatically downcode higher-level E/M visits (99204-05, 99214-15, 99244-45) without warning.

But let’s be clear: Cigna is not alone. 👀
Humana, Aetna, and BlueCross BlueShield have already dipped their toes (or whole feet) into this “down-leveling” game. 🕹️

💡 What this means for you:
• Double-check your EOBs 🧾 for sneaky downgrades.
• If your level 5 somehow comes back as a level 4… 📉 don’t just sigh, appeal it with documentation.
• Ask payers to explain the algorithm (they may mumble something about “proprietary processes” 🤔).
• If it feels unfair, file a complaint with your State Department of Insurance. They do want to hear from you.
• Connect with your state medical society — many are already fighting back. 🥊

📨 Want a ready-to-use appeal template? 👉 Contact us via Messenger and we’ll send you a copy.

Sage Advice 🌿

If your work gets unfairly “down-leveled,” remember: you don’t have to be. Stand tall, document well, and push back with confidence.

Hashtags

09/13/2025

🕯️🚨 We're publishing on Friday the 13th?

Don’t worry—no black cats or broken mirrors here… just healthcare changes you can predict.

Heads-up, healthcare heroes!

October 1 is just around the corner, and you know what that means—brace yourselves for a wave of new healthcare updates. From brand-new ICD-10 codes to quality rule tweaks, CLIA-waived lab updates, and more quality measures, this is the annual “reset button” for coding and compliance.

Here’s what’s coming your way (no spooky surprises, we promise):

🩺 ICD-10 Updates:
The fresh FY 2026 ICD-10-CM and ICD-10-PCS codes take effect October 1, 2025, and run through September 30, 2026. ICD-10-CM covers diagnoses, while ICD-10-PCS is the inpatient procedure coding system—used primarily in hospitals to describe surgeries, imaging, and complex interventions. Together they bring hundreds of changes, from new codes to revisions and retirements. Translation: accuracy (and coffee) will be your best friend.

💻 Telehealth Rollback:
Those pandemic-era telehealth freedoms are winding down. Starting October 1, most Medicare telehealth visits must once again originate from rural medical facilities—not from your living room recliner in Memphis or Jackson. The big exception is for mental and behavioral health, where flexibility remains. Time to dust off those office chairs! This will also be impactful for INCIDENT TO SERVICES! The Provider must return to "hollering distance" to bill PAs and NPs incident to.

💊 Controlled Substances:
One silver lining—telehealth prescribing of controlled medications continues under the extended flexibilities until December 31, 2025. So if you’ve been prescribing responsibly from your office (with or without fuzzy socks), you can keep doing so for now but NOT beyond January 1, 2026.

📊 Quality Rules & CLIA-Waived Labs:
October 1 also ushers in new quality reporting measures and changes to the list of CLIA-waived tests. These adjustments may look small on the surface but can ripple into compliance checks and reimbursement. We’ll break down the details in future posts.

The big picture:

New ICD-10 code set lands October 1

Telehealth mostly rolls back to pre-COVID rules (except mental health)

Controlled-substance prescribing flex stays through 2025

Quality and CLIA updates arrive the same day

So yes, it’s Friday the 13th—but unlike superstition, these changes aren’t lurking in the shadows. They’re clear, official, and headed straight for your inbox. Stay calm, caffeinated, and compliant. Peace will prevail ☮️

09/05/2025

🚨 Medicare Signature Rules: More Than Just a Scribble! 🖊️

When it comes to Medicare claims, your signature isn’t just a formality—it’s the key that proves services were ordered, provided, and properly documented. Miss it, and you might be waving goodbye to payment. 💸

Here’s what you need to know (and yes, CMS really spells it out):

✔️ Handwritten signatures must clearly show your approval or obligation. (Illegible chicken scratch? Use a signature log!)
✔️ Stamped signatures are not accepted—unless you have a disability and CMS has proof.
✔️ Scribes & AI are allowed for documentation—but the provider must still sign to authenticate. 🤖
✔️ Missing signatures? You can file an attestation (except for orders). Think of it as a belated “Yes, I really meant that.”
✔️ Medical students can document, but you must review and sign. No shortcuts here.
✔️ Electronic signatures are fine—just make sure the system prevents alteration and meets legal safeguards.

👉 Pro tip: Submitting signature logs or attestations up front can prevent delays with contractors like RACs, CERT, and MACs.

At the end of the day, Medicare reviewers are less interested in your penmanship style and more in whether your signature proves authenticity. So, take a second to sign—it might just save your claim! ✅

09/03/2025

🧾 Prior Auth Rule: Faster Answers, Fewer Headaches (we hope)

Good news (with a compliance twist): CMS finalized big prior authorization changes that should speed things up—for payers and for your patients.

What’s changing?
• Certain payers (including Medicare Advantage) must issue PA decisions within 7 calendar days (standard) and within 72 hours (expedited). Starts Jan 1, 2026. CMS
• CMS is also pushing payers to modernize with APIs (tech rails for PA + data sharing). Most API pieces land by Jan 1, 2027. CMS

Why practices should care:
• Faster PA decisions = fewer limbo days for scheduling and cash flow.
• Clearer denial reasons must be provided, which helps your team fix & resubmit without guesswork. CMS

Where this applies:
• Impacts Medicare Advantage, Medicaid/CHIP, and certain Marketplace plans (QHP issuers). Traditional Medicare fee-for-service isn’t the target here, but many of your patients are on MA, so your front office still feels the difference. CMS

KLA Take: Think of this as upgrading from fax-era traffic to an express lane. You’ll still need your checklists, but the lights should turn green faster.

✅ Action for offices:
1. Map your top PA services and note which payers are impacted.
2. Tighten your documentation templates now (so you’re ready for faster resubmits).
3. Ask MA plans about their 2026 timeline and API plans for 2027.

09/03/2025

🚑📊 Medicare, Category II Codes & Your Bottom Line

Think Category II codes don’t matter because you’re billing traditional Medicare?

Think again!

These little “zero-dollar” codes don’t pay a dime directly, but they speak volumes to CMS. Why? Because Medicare uses them (and other quality reporting data) to feed into MIPS (Merit-based Incentive Payment System).

👉 Under MIPS, your practice’s performance is scored, and that score adjusts your Medicare Part B payments up or down. In fact, payment rates can swing by as much as +9% or –9% depending on your score. That’s not pocket change.

Category II codes are one of the fastest ways to prove you’re hitting quality benchmarks (like documenting blood pressure control, smoking cessation counseling, or medication reconciliation).

If you don’t report these measures, Medicare assumes you didn’t do them—ouch.

And it’s not just Medicare:
• Medicare Advantage plans and commercial insurers also use Category II codes to track quality measures. They tie them to Star Ratings and pay-for-performance bonuses.
• Translation: everyone’s watching these little codes, even if they’re not writing checks for them.

So next time you’re tempted to skip a Category II code because “Medicare doesn’t pay for that,” remember:
💡 They may not pay for the code, but they sure can pay you less if you don’t use them.

✅ KLA Tip: Think of Category II codes as the broccoli of billing. They may not be your favorite, but they help keep your Medicare reimbursements healthy.

08/27/2025

The DOJ is looking into business practices at UnitedHealth’s PBM Optum Rx, in addition to its ongoing probe into the company's Medicare billing practices.

08/27/2025

⚡️ AI in Healthcare: Friend, Not Foe (But Keep an Eye on It!) 🩺🤖

Artificial Intelligence isn’t just for Silicon Valley—it’s quietly transforming small medical practices. The good news? It’s more likely to take over your paperwork than your job. (And let’s be honest, no one will complain about that 😉).

Here’s where AI shines—and where you still need to keep your human brain switched on:

✅ AI Scribes
Tools like Nuance DAX, Suki AI, and DeepScribe “listen” to visits and generate notes. Major time-saver, but remember: HIPAA compliance is a must so verify platforms source and certification Also notes can contain errors. Always verify before signing—because AI makes guesses, and you make judgments. 🚨

✅ EHR Add-Ons (ECW, Practice Fusion, etc.)
Optional AI modules suggest codes, scrub claims, or transcribe dictation. Helpful, but beware: suggested billing codes often lean toward upcoding. Treat them like a pushy sales rep—review before you buy in. 🧐

✅ Clinical Question Prompts
Some platforms (like Isabel Healthcare, VisualDx, or Nuance DAX Copilot) can suggest diagnostic questions you may have overlooked. They’re not there to replace your expertise, but they can help catch blind spots and improve documentation. Use them as a reminder, not a decision-maker—you’re still the captain of the ship. 🧭

✅ Prescription Safety
From the start, AI has been keeping watch over drug interactions, allergies, and dosing errors. Tools like First Databank (FDB MedKnowledge), Epocrates, and integrated EHR drug-checkers flag potential problems before they reach the pharmacy. Some even suggest cost-saving alternatives or check formulary coverage. 💊 Just remember—AI can catch the obvious, but only you know the patient in front of you.

✅ Insurance Verification
Platforms like Availity, Waystar (Zirmed), and Change Healthcare confirm eligibility in real time, updating patient coverage before the appointment. They’re like digital bouncers keeping bad insurance surprises out of your waiting room. 🦸

✅ Text Reminders
Systems such as Solutionreach, Weave, and Klara text patients when an appointment is booked…and again when it’s time to schedule their next one. Because patients will forget. And then forget they forgot. 📱➡️💭

👉 The takeaway? AI can handle the sticky notes, phone tag, eligibility calls, and even flag risky prescriptions. But it’s not your replacement—it’s your sidekick. You provide the care, the compassion, and the compliance.

Now you’ve got more time for what matters—your patients (and maybe sneaking in that second latte ☕).

KLA Healthcare Consultants

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