Understanding the 2026 SNF Final Rule updates

In this installment of "WTH were they thinking?", take a look at this case study. The WellRithms, Inc. team of physicians review complex procedures to review excess charges and unnecessary billing. Doing more than a data scrub, physicians review actual billing codes to remove the bloat from the claims spend while still ensuring that physicians are profitable on a line by line basis. Payment Integrity is a simple process that does not require additional PEPM fees and should be part of a comprehensive benefit strategy. This is what we call #LevelingThePayingField. #StopOverpayingForHealthcare #WellRithms #PaymentIntegrity #CostPlusClaimsAuditing

Hospital CFOs- Thinking Your Clinical Documentation Integrity Programs Are Contributing To Your Bottom Line Monthly: Reality- Your CDI Program after factoring in all sunk costs including opportunity costs of alleviating payer denials associated with poor documentation not addressed by current CDI processes, is a net loss of $2.3 million. This does not factor in compliance risks and potential paybacks for aberrant coding and billing patterns amounting to upcoding, an inherent risk of all CDI programs. Reach out to discuss clinical transformation of CDI, CDI 2.0, alleviating costly payer denials by focusing on the medical record as a communication tool versus today's model of reimbursement tool. #CDI, #reimbursementool, Cesar M Limjoco MD, #compliancerisk, #cdiprogramsarelosingmoney, #cdisunkcostslosingproposition

CDS5R: Clinical Decision Support Five Rights. CDS5R is a framework that helps us deliver the right clinical decision support information to the right person, in the right format and channel, at the right time in the workflow so it actually helps care instead of cluttering it. #CDS #clinicaldecisionsupport #clinicalinformatics

The Funding Foundation Behind Many QIP Indicators Ontario’s Health-Based Allocation Model (HBAM) has linked hospital funding to performance since 2012. Up to 70% of a hospital’s annual funding is based on cost per weighted case, which in turn is derived from physician documentation and coding. Efficiency is measured in terms of cost per weighted case, which is directly tied to HIM-coded documentation based on physician records. QIP indicators that track readmission rates or average length of stay rely on these same building blocks. That means documentation accuracy directly affects reported outcomes, funding, and performance benchmarks. Better documentation isn’t just about compliance. It’s the foundation for every funding metric we rely on.

ICYMI: The deal to end the shutdown includes a 30-day delay of the steep Medicare Clinical Lab Fee Schedule cuts slated for January 1, 2026. Without action, more than 800 tests faced reductions of up to 15% under PAMA. 📉 Labs now gain a brief reprieve, and Congress has more time to work on long-term payment reform. These annual reduction freezes have been in place since the pandemic, but they don’t solve the underlying instability labs face when forecasting reimbursement and managing financial risk. ⬇️ Bottom line: The delay in rate reductions is helpful, but the industry still needs a permanent fix for PAMA. Support for the RESULTS Act remains critical to ending these year-to-year cuts and protecting patient access to essential testing. If your lab has questions about revenue cycle planning, reimbursement strategy, or payer negotiations in light of these developments, our RCM Consulting Team is here to help.

Payer negotiations don’t have to feel one-sided. With the right data, preparation and confidence, even small practices can secure fair contracts and meaningful reimbursement increases. This guide breaks down actionable strategies to help administrators: ✅ Build a business case using real performance data ✅ Avoid “trapdoor” clauses that erase rate wins ✅ Leverage metrics that prove your value at the table 💬 Negotiation isn’t a one-time event — it’s a core business skill every practice leader needs. 📄 Read more: https://hubs.li/Q03RzLxK0 #PhysiciansPractice #PayerNegotiation #PracticeManagement #RevenueCycle #PhysicianLeadership #IndependentPractice

CPT 99417 is an add-on code for prolonged evaluation and management (E/M) services, billed in 15-minute increments to capture time spent beyond the usual limits. Patient visits don’t always fit neatly into standard time slots sometimes, extra care, counseling, and attention go well beyond expectations. That’s where CPT 99417 makes the difference, ensuring providers are properly reimbursed for every extra 15 minutes of dedicated patient care. ✅ Applies only with: - 99205 (new patient, highest level) - 99215 (established patient, highest level) ⏱️ Time thresholds: - 99205: 60 mins base → first 99417 at 75 mins - 99215: 40 mins base → first 99417 at 55 mins ⚠️ Medicare Note: CMS does not recognize CPT 99417. Instead, providers should bill **HCPCS G2212** for prolonged services. 📋 Documentation Tip: Record total time on the day of the encounter and specify activities such as reviewing records, counseling, patient examination, and ordering tests. 👉 Accurate coding protects compliance and ensures providers are reimbursed for the time and value they deliver. 📞 To know more about correct billing practices, reach out to our experts at HealthQuist! Reach out now: https://lnkd.in/gve5DGP5 #MedicalCoding #ProlongedServices #EandMCode #HealthcareCompliance #RCMExperts

I keep drawing new conclusions from the CY 2026 Physician Fee Schedule that affect all MSSP ACOs. CMS will now let ACOs benchmark with <5,000 beneficiaries in BY1/BY2 as long as they’re at 5,000 in BY3. That’s good for overall participation. But if you dip below 5,000 in any benchmark year, CMS can apply an alternate/shared savings cap and keep you in the BASIC track instead of the ENHANCED track. That’s the real constraint. Why this still matters for everyone in 2026: 1. CMS will let you be small. It just won’t let a small, volatile panel translate into outsized upside or downside. 2. More competition to lock up high attribution TINs so you don’t accidentally fall under 5k. That is particularly relevant for groups with agreement periods beginning in 2027. 3. Now that CMS has clarified skin substitute payment and is targeting the “one bad actor = everyone loses” problem, it reduces the fear that ACOs will suffer from someone else’s outlier wound care expenses, making entry a bit less risky.

Did You Know? Medical Exceptions Can Be the Game-Changer Between Denial and Approval. While most professionals are familiar with prior authorizations and appeals, medical exceptions remain an underutilized tool in securing access, especially for treatments that fall outside formularies or standard protocols. From newly approved therapies to severe contraindications and cost-sharing barriers, medical exceptions: ✅ Let providers advocate based on individual medical necessity ✅ Rely on strong documentation - LMNs, peer-reviewed studies, and payer policy ✅ Can override step therapy or formulary exclusions when done right 💡 Key insight from Ned Woody, MBA: “The sequence matters. File the wrong form too early and you could lose the right to request an exception altogether.” 👉PACS™-certified professionals know how to: -Navigate payer portals -Build exception documentation correctly -Cut denial delays and secure approvals faster 📈 PACS grads report a 44% increase in approvals after first claim submission and a 37% reduction in time to PA approval. Learn how PACS™ helps you master the full access spectrum, from prior auths to appeals to exceptions: https://hubs.ly/Q03S4LPn0 #Blog #PriorAuthorization #MedicalExceptions #PACS #AccessAndReimbursement #HealthcareLeadership #InsuranceNavigation #PatientAccess #ACMA

In their new Forefront article, Richard Heller, C. Ryan Keay, Christopher Cook, Freeman Jackson, and Malea Reising from Radiology Partners discuss how the No Surprises Act has protected patients from surprise medical bills. However, the law’s incentives for insurers acting as third party administrators to push providers out of network and under-reimburse for care drive wasteful spending that harms patients, plans, and providers. "The independent dispute resolution (IDR) process is costly. The non-refundable, per-dispute administrative fee is $115, and the fees for the arbiters, called IDR entities (IDREs), range from $200 to $1,173 or more. While the IDRE fee is refundable to the prevailing party, it must be paid upfront. Despite these expenses, the volume of IDR dispute submissions has continued to grow since the program’s inception. Our analysis of the Public Use Files (PUF) data reveals that in just the second half of 2024, there were approximately 26 percent more dispute submissions initiated (853,374) than in all of 2023 (679,156). There have been another 1.4 million disputes submitted in the first 7 months of 2025. Two main factors contribute to the rising volume of IDR cases: expanded access to IDR and persistent demand." Read the full article here: https://bit.ly/4qpToLI