Human Medical

10/03/2025

no referral? denied may 1, 2026.
uhc medicare advantage is rolling out big referral changes. members must see their p*p first before specialists. providers, get your workflows ready.
hashtags:

09/19/2025

𝗠𝗲𝗱𝗶𝗰𝗮𝗿𝗲’𝘀 𝗽𝗵𝘆𝘀𝗶𝗰𝗶𝗮𝗻 𝗳𝗲𝗲 𝘀𝗰𝗵𝗲𝗱𝘂𝗹𝗲 𝗱𝗿𝗼𝗽𝗽𝗲𝗱 𝗮𝗻𝗼𝘁𝗵𝗲𝗿 𝟮.𝟴𝟯% 𝗶𝗻 𝟮𝟬𝟮𝟱, 𝘄𝗵𝗶𝗹𝗲 𝗽𝗿𝗮𝗰𝘁𝗶𝗰𝗲 𝗰𝗼𝘀𝘁𝘀 𝗸𝗲𝗲𝗽 𝗰𝗹𝗶𝗺𝗯𝗶𝗻𝗴 𝟯.𝟱% 𝗮 𝘆𝗲𝗮𝗿.

2025 updates :

fees: conversion factor at $32.35; radiology saw deeper cuts (breast tomosynthesis down 9.67%)

cpt codes: 420 changes — 270 new, 112 deleted, 38 revised

prior auth: new 10-day post-service review windows with some payers

no surprises act: 25m surprise bills prevented since 2022, but documentation gaps remain

key kpis: clean claim rate ≥98%, denial rate

US medical billing 2025 explained: fee schedule updates, CPT code changes, prior authorization rules, IDR issues, & proven RCM playbook for providers.

09/16/2025

𝟵𝟯% 𝗼𝗳 𝗱𝗼𝗰𝘁𝗼𝗿𝘀 𝘀𝗮𝘆 𝗽𝗿𝗶𝗼𝗿 𝗮𝘂𝘁𝗵𝗼𝗿𝗶𝘇𝗮𝘁𝗶𝗼𝗻𝘀 𝗱𝗲𝗹𝗮𝘆 𝗽𝗮𝘁𝗶𝗲𝗻𝘁 𝗰𝗮𝗿𝗲 — and in 2025, 𝗱𝗲𝗻𝗶𝗮𝗹𝘀 𝗮𝗿𝗲 climbing to 𝟭𝟮–𝟭𝟱%.

that means more hours lost on paperwork, more delayed reimbursements, and more nights fixing claims instead of focusing on patients.

𝗮𝗶 𝗮𝗻𝗱 𝗮𝘂𝘁𝗼𝗺𝗮𝘁𝗶𝗼𝗻 aren’t buzzwords anymore-

coding ai reduces error rates by 𝘂𝗽 𝘁𝗼 𝟳𝟬% (𝗮𝗵𝗶𝗺𝗮)

predictive denial tools spot rejections before claims even go out

𝗮𝘂𝘁𝗼𝗺𝗮𝘁𝗲𝗱 𝗰𝗹𝗮𝗶𝗺𝘀 + 𝗽𝗮𝘆𝗺𝗲𝗻𝘁 reminders shorten the revenue cycle and boost patient collections

providers who adopt these tools are already 𝗹𝗼𝘄𝗲𝗿𝗶𝗻𝗴 𝗱𝗲𝗻𝗶𝗮𝗹 𝗿𝗮𝘁𝗲𝘀, speeding up payments, and reducing staff burnout.

Are your physicians still spending nights fixing denied claims , or has your practice started preventing them?

𝗪𝗮𝗻𝘁 𝘁𝗼 𝗳𝗶𝘅? 𝗳𝘂𝗹𝗹 𝟮𝟬𝟮𝟱 𝗴𝘂𝗶𝗱𝗲 𝗵𝗲𝗿𝗲 → https://humanmedicalbilling.com/blog/how-ai-and-automation-are-revolutionizing-medical-billing-processes-in-2025/

See why medical billing needed change, how AI and automation improve revenue cycles in 2025, with benefits, trends, adoption steps, and future outlook.

09/16/2025

𝗺𝗲𝗱𝗶𝗰𝗮𝗿𝗲 just l𝗮𝘂𝗻𝗰𝗵𝗲𝗱 𝗮 𝟲-𝘆𝗲𝗮𝗿 𝗽𝗶𝗹𝗼𝘁 where 𝗮𝗶 𝗱𝗲𝗰𝗶𝗱𝗲𝘀 if your 𝘁𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁 𝗴𝗲𝘁𝘀 𝗮𝗽𝗽𝗿𝗼𝘃𝗲𝗱.

called the 𝗰𝗺𝘀 𝘄𝗶𝘀𝗲𝗿 𝗺𝗼𝗱𝗲𝗹 (wasteful & inappropriate services reduction), 𝗶𝘁 𝘄𝗲𝗻𝘁 𝗹𝗶𝘃𝗲 𝗶𝗻 𝗷𝘂𝗹𝘆 𝟮𝟬𝟮𝟱 𝗮𝗰𝗿𝗼𝘀𝘀 𝗮𝗿𝗶𝘇𝗼𝗻𝗮, 𝗻𝗲𝘄 𝗷𝗲𝗿𝘀𝗲𝘆, 𝗼𝗵𝗶𝗼, 𝗼𝗸𝗹𝗮𝗵𝗼𝗺𝗮, 𝘁𝗲𝘅𝗮𝘀, 𝗮𝗻𝗱 𝘄𝗮𝘀𝗵𝗶𝗻𝗴𝘁𝗼𝗻.

here’s what it means:

ai screens 17 high-risk services before medicare pays

contractors are paid for savings, not volume of denials

goal = cut billions in wasteful spending without blocking needed care

but doctors are worried:

40 house democrats warned cms against “for-profit pa firms”

providers fear more paperwork + delayed treatments

cms says it will shut down the pilot if patient access is harmed

early signs: prior auth pilots (like orthoses in 2022) cut spending from $33.5m → $8.8m in just over a year.

self-check: if you practice in a pilot state, are you ready to document and submit prior auths under ai review?

We have made a full breakdown of cms’s 2025 ai prior auth model →
https://humanmedicalbilling.com/blog/cms-wiser-model-medicare-ai-powered-prior-authorization-test-to-cut-waste-2025/

In 2025, Medicare’s new AI-driven prior authorization test aims to cut wasteful spending, improve billing efficiency, and ease provider and patient challenges.

09/14/2025

𝗕𝘆 𝘁𝗵𝗲 𝗲𝗻𝗱 𝗼𝗳 𝘁𝗵𝗶𝘀 𝘆𝗲𝗮𝗿 , denial rates in u.s. healthcare are projected to reach 𝟭𝟮–𝟭𝟱% , nearly 𝘁𝗿𝗶𝗽𝗹𝗲 the best-practice 𝘁𝗮𝗿𝗴𝗲𝘁 𝗼𝗳 50 = red flag

clean claim rate: industry pushes for ≥95% first-pass success

denial rate: trending 12–15% in 2025; target $5k

cost to collect: leaders hold at ≤2%, aided by automation

over 60% of u.s. providers now use ai in rcm - not experimental anymore, but mainstream in denial prediction, coding, and prior auth automation.

Do you know your 2025 denial rate and ncr — or are you waiting until cash flow becomes the wake-up call?

Check full 2025 kpi breakdown here →

Learn the key medical billing KPIs for 2025 - days in A/R, clean claim rate, denial rate, and net collection rate that drive cash flow and revenue cycle growth.

09/14/2025

𝟰𝟯% 𝗼𝗳 𝗨.𝗦. 𝗽𝗵𝘆𝘀𝗶𝗰𝗶𝗮𝗻𝘀 𝗿𝗲𝗽𝗼𝗿𝘁𝗲𝗱 𝗯𝘂𝗿𝗻𝗼𝘂𝘁 𝗶𝗻 𝟮𝟬𝟮𝟰 and one of the biggest culprits was and is EHR “pajama time.”

Doctors spend 8–10 extra hours a week at home charting, replying to inbox messages.

A JAMA study shows 𝗷𝘂𝘀𝘁 𝟲 𝗺𝗶𝗻𝘂𝘁𝗲𝘀 𝗼𝗳 𝗮𝗳𝘁𝗲𝗿-𝗵𝗼𝘂𝗿𝘀 𝗘𝗛𝗥 𝗽𝗲𝗿 𝘃𝗶𝘀𝗶𝘁 𝗮𝗱𝗱𝘀 𝘂𝗽 𝗳𝗮𝘀𝘁.

That time doesn’t just eat into family life , it doubles burnout risk and costs hospitals $𝟮𝟱𝟬𝗞–$𝟱𝟬𝟬𝗞 𝗽𝗲𝗿 𝗽𝗵𝘆𝘀𝗶𝗰𝗶𝗮𝗻 𝗶𝗻 𝘁𝘂𝗿𝗻𝗼𝘃𝗲𝗿.

But here’s what works:

Templates + pre-visit planning 𝗰𝘂𝘁 𝗰𝗵𝗮𝗿𝘁𝗶𝗻𝗴 𝗯𝘆 𝟮𝟱%

Inbox pooling/routing reduces message overload

Delegating denials & prior auths frees doctors’ evenings

AI scribes show promise in primary care & OB/GYN

One Midwest clinic cut pajama time 𝟯𝟴% 𝗶𝗻 𝟵𝟬 𝗱𝗮𝘆𝘀 after redesigning inbox workflows and outsourcing billing tasks.

Are your physicians logging more than 5 hours of pajama time a week?

Read the full breakdown → https://humanmedicalbilling.com/blog/how-cutting-after-hours-charting-helps-reduce-ehr-time-for-doctors/

Discover how reducing after-hours EHR charting helps doctors save time, cut burnout, and improve workflow efficiency. do this 30/60/90-day roadmap.

09/14/2025

𝗖𝗮𝗹𝗶𝗳𝗼𝗿𝗻𝗶𝗮 𝗽𝗿𝗮𝗰𝘁𝗶𝗰𝗲𝘀 𝘀𝗽𝗲𝗻𝗱 𝘂𝗽 𝘁𝗼 $𝟭𝗠 𝗮 𝘆𝗲𝗮𝗿 𝗼𝗻 𝗺𝗲𝗱𝗶𝗰𝗮𝗹 𝗯𝗶𝗹𝗹𝗶𝗻𝗴.
In 2025, average costs run 3–8% of collections or $3–$10 per claim.

That’s higher than most states — thanks to:
– Knox-Keene compliance
– Medi-Cal’s strict filing rules
– And some of the country’s highest staffing costs

Outsourcing cuts expenses by 30–40% and lifts net collections to 90–95%.
For one LA pediatric clinic, that meant $225k in savings + new revenue in a single year.

So what’s the real cost of billing in California, and how do practices reduce it?

know here: https://humanmedicalbilling.com/blog/medical-billing-services-cost-california-2025/

Learn key factors in California billing costs: staffing, payer mix, denials, and AI. See 2025 trends & how the right partner cuts expenses & ensures compliance.

09/13/2025

𝟯𝟬% 𝗼𝗳 𝗰𝗹𝗮𝗶𝗺 𝗱𝗲𝗻𝗶𝗮𝗹𝘀 𝗰𝗼𝗺𝗲 𝗳𝗿𝗼𝗺 𝗰𝗼𝗱𝗶𝗻𝗴 𝗲𝗿𝗿𝗼𝗿𝘀.
Billions lost before revenue even reaches providers.

𝗠𝗲𝗱𝗶𝗰𝗮𝗹 𝗰𝗼𝗱𝗶𝗻𝗴 isn’t back-office paperwork.
It’s the first checkpoint of the revenue cycle.

Done right → fewer denials, faster payments, cleaner data.
Done wrong → stalled cash flow, compliance risk, patient frustration.

How to do it right?
We broke it down here 👇
https://humanmedicalbilling.com/blog/what-is-medical-coding/

Learn what medical coding is, why it matters in healthcare, & how coders use ICD-10, CPT, & HCPCS codes. Explore key roles, certifications, & future trends.

09/12/2025

𝗗𝗼𝗰𝘁𝗼𝗿𝘀...𝗦𝘁𝗮𝗿𝘁𝗶𝗻𝗴 𝗢𝗰𝘁𝗼𝗯𝗲𝗿 𝟭, 𝟮𝟬𝟮𝟱, 𝗖𝗶𝗴𝗻𝗮 will 𝗯𝗲𝗴𝗶𝗻 𝗱𝗼𝘄𝗻𝗰𝗼𝗱𝗶𝗻𝗴 high-level E/M visits.

Codes like 99204, 99205, 99214, 99215 will face extra review.

If documentation doesn’t meet AMA’s 2021 E/M guidelines, Cigna can lower the level → and cut your payment.

For providers, that means:
– More scrutiny of high-complexity visits
– Higher risk of revenue loss
– More appeals and admin time

This isn’t about overbilling.
It’s about whether your notes prove the complexity of care you delivered.

how to protect your revenue before October?… the answers are below.

Learn how Cigna’s new E/M downcoding policy starting October 2025 impacts CPT codes and reimbursements. Discover steps to protect revenue.

09/12/2025

𝗡𝗲𝘅𝘁 𝘆𝗲𝗮𝗿, 𝘆𝗼𝘂𝗿 𝘄𝗮𝗶𝘁𝗶𝗻𝗴 𝗿𝗼𝗼𝗺 𝗰𝗼𝘂𝗹𝗱 𝗯𝗲 𝗳𝘂𝗹𝗹 𝗼𝗳 𝗽𝗮𝘁𝗶𝗲𝗻𝘁𝘀 𝘄𝗶𝘁𝗵 𝗵𝗶𝗴𝗵 𝗱𝗲𝗱𝘂𝗰𝘁𝗶𝗯𝗹𝗲𝘀 𝗮𝗻𝗱 𝗻𝗼 𝘄𝗮𝘆 𝘁𝗼 𝗽𝗮𝘆 𝘂𝗽𝗳𝗿𝗼𝗻𝘁.

Premiums are projected to 𝗿𝗶𝘀𝗲 𝟭𝟱% 𝗶𝗻 𝟮𝟬𝟮𝟲.
CMS will expand catastrophic plan eligibility to millions more adults under 65.

For providers, that means:
– More financial counseling at intake
– Higher AR workloads
– Greater strain on cash flow

If your teams aren’t preparing for 𝗝𝗮𝗻𝘂𝗮𝗿𝘆 𝟮𝟬𝟮𝟲 now… the impact may hit harder than expected.

We’ve made a guide to help:
https://humanmedicalbilling.com/blog/cms-expands-access-to-catastrophic-health-insurance-plans-starting-2026/

CMS expands catastrophic health plan access in 2026. Find out how providers can prepare for changes in billing, eligibility, and revenue cycle management.

09/11/2025

$𝟴𝟲 𝗯𝗶𝗹𝗹𝗶𝗼𝗻 𝗶𝗻 𝗠𝗲𝗱𝗶𝗰𝗮𝗿𝗲 𝗔𝗱𝘃𝗮𝗻𝘁𝗮𝗴𝗲 𝗯𝗲𝗻𝗲𝗳𝗶𝘁𝘀 𝘄𝗲𝗻𝘁 𝘂𝗻𝘂𝘀𝗲𝗱 𝗹𝗮𝘀𝘁 𝘆𝗲𝗮𝗿.
Dental. Vision. Wellness. Even transportation.

𝗖𝗠𝗦 planned to require mid-year notices so patients would know what’s available.
Now? 𝗧𝗵𝗮𝘁 𝗿𝘂𝗹𝗲 𝗶𝘀 𝗼𝗻 𝗵𝗼𝗹𝗱.

For providers, this pause means 𝘁𝘄𝗼 𝘁𝗵𝗶𝗻𝗴𝘀:
– Less compliance pressure.
– More responsibility to educate patients directly.

Unused benefits aren’t just missed care.
They’re missed revenue.

If CMS asked you tomorrow how you’re helping patients use their benefits… would you be ready?

We’ve outlined 12 steps practices can take now while CMS delays the policy below

https://humanmedicalbilling.com/blog/cms-delays-medicare-advantage-unused-benefits-policy-impact-on-healthcare-providers/

CMS has delayed its mid-year alerts for unused supplemental benefits, giving Medicare Advantage plans more time to set up tracking, communication systems.