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The 6-Stage Revenue Cycle: Why Claim Submission Is Your Last Line of Defense
Most group practices treat claim submission as step one. The data says it should be step six. Here is the 6-stage revenue cycle sequence that stops denials before they start.
It Is Not Always a Billing Problem
Your payments are low. Your aging claims are climbing. Your instinct says the billing is broken. Sometimes it is. Often it is not. Some of the most expensive leaks in a practice have nothing to do with billing at all. Leak one: the contract. Reimbursement is not what the payer decides. It is what your contract says. Contracts vary widely for the same code in the same market, and most owners have never compared theirs. Do you know your contracted rate for your top five CPT cod
Your Denials Were Decided Before the Claim Left Your Office
Change Healthcare research found 86% of claim denials are potentially avoidable. Read that again. Eighty-six percent. That number ends the debate about whether denials are just the cost of doing business. They are not. They are the cost of a broken front end. Most denials are not payer mysteries. They are front-end failures. Wrong demographics. Expired eligibility. Missing authorizations. Incomplete claim data. The claim was doomed before it left your office, and nobody knew,
Do You Actually Know Your Numbers?
Three numbers run your revenue cycle. Most practice owners cannot name one of them. Your denial rate. Your clean claim rate. The share of your accounts receivable sitting past 90 days. These are not accounting trivia. They are the vital signs of your practice. A doctor would never treat a patient without vitals. Yet owners run million-dollar practices without ever checking theirs. Here are the lines, so you know what good looks like. MGMA benchmarks say your clean claim rate
Practice leaders want pay for audits that find nothing
At MGMA's government affairs town hall on Sept. 29, an Alaska practice leader turned the tables on downcoding audits: if an insurer audits your charts and finds the claims were coded correctly, the insurer should pay for your time. MGMA is shopping draft legislation that would prohibit automatic downcoding by Medicare Advantage plans, with a fallback that permits it only after a plan proves a physician upcoded above a set rate. Much of the burden comes from self-funded ERISA
Providence sees 73% rise in denials and underpayments
Hospital CEOs stopped treating revenue cycle as back-office work and started treating it as 2027 strategy. Cleveland Clinic still has more than 15% of claims initially denied, a grind its CFO calls unsustainable. In Becker's CEO roundup, seventeen systems say payers now review claims with AI at a scale providers have not matched.
Psychologists likely to see Medicare revenue rise
The proposed 2027 physician fee schedule nets clinical psychologists about 11% on RVU changes, even as overall base rates drop (New England Psychologist). The lift comes from a four-year RVU reevaluation that separates therapy services from other medical services and finalizes in 2027, with CMS due to publish final rates November 1 for a January 1 start.
Patients help feds build Medicaid fraud case against QBH
A week after FBI raids upended Quality Behavioral Health's Michigan centers, the Justice Department filed to keep the $18.7 million in cash and precious metals seized from owner Naveed Syed. Court filings allege patients were forced into 12-hour workdays while QBH billed Medicaid for services never delivered, with $52,000 stashed in a safe above a toilet. Syed's lawyer asked a judge September 29 to appoint a receiver, arguing the seizures left patients without care, and no cr
Norman Regional and UnitedHealthcare reach a deal to stay in network
UnitedHealthcare and Norman Regional Health System reached a new agreement on September 29 that keeps the system's providers, Norman Regional Hospital, and Norman Regional Moore Hospital in network across its commercial and Medicare Advantage plans. The deal takes effect immediately, and UHC will mail new letters to members it had previously warned about a possible exit. A September 23 roundup had listed Norman Regional as set to leave UHC's Medicare Advantage network in Octo
Medicare Advantage marketing rules loosen today
Medicare Advantage marketers get a wider lane starting today. CMS's final 2027 rule lifts several limits on how agents, brokers, and third-party marketers can contact beneficiaries, just as 2027 plan marketing ramps up. The Medicare Rights Center expects a noticeably higher volume of calls, mailers, and ads this season. The same rule strips quality measures from Star Ratings, including call-center and appeals-handling metrics that insurers long argued were applied unfairly. C
