Prospective risk adjustment is rapidly becoming essential for healthcare providers navigating the Centers for Medicare & Medicaid Services (CMS) hybrid payment models. Unlike retrospective methods, this proactive approach uses real-time clinical data, predictive analytics, and social determinants of health (SDOH) to forecast patient risks and close
We’ve assembled the latest news for healthcare revenue cycle leaders to help you stay on top of industry challenges and adapt your revenue cycle management services to the challenges of USA medical billing.
CMS has published memos for week five, May 26-30. This applies to the reporting period 2025. Download is available under file name 5th-week-of-may-26-30-2025.zip [1]. This change can directly impact USA medical billing.
CMS has released the Medicare Advantage Prescription Drug System payment information for June of 2025. It was issued as of May 30, 2025. The file is available for download under the name “medicare_advantage_prescription_drug_system_june_2025_payment_information_g.pdf” [2]. This release is pertinent for revenue cycle management services.
The agency has released the updated versions of the HETS Companion Guides. This applies to the current implementation (HETS2025-1) and the upcoming HETS2025-2 release. The guide updates are associated with changes to SOAP + WSDL (“SOAP”) and MIME connectivity options [3]. Multiple sections cover impact to medical billing.
CMS has announced changes to the ACO REACH model. This includes financial methodology with a goal of ensuring future cost savings for the accountable care pilot program. These changes to improve ACO REACH will be applied beginning in 2026 [4]. This update pertains to any provider engaging in medical billing for attributed beneficiaries.
CMS has posted the Shared Savings Program Applications dates for the January 1, 2026 start date. These dates include phase 1 submission, RFI-1, RFI-2, final disposition, as well as phase 2 dates [5].
CMS has published the official update of the HCPCS medical coding system for public use. It was updated May 13, 2025 and is available under file name “July 2025 Alpha-Numeric HCPCS File (ZIP)” [6]. This update impacts medical coding in USA.
The agency has released updated price transparency guidance which can impact the hospital revenue cycle. The guidance falls under the presidential executive order, “Making America Health Again by Empowering Patients with Clear, Accurate and Actionable Healthcare Pricing Information”. The guidance falls under executive order 14221 [7].
In revenue cycle services news, CMS has premiered a strategy for expanding its auditing of Medicare Advantage plans. The announcement explains that, beginning immediately, CMS plans to audit all eligible Medicare Advantage contracts for each corresponding payment year under all newly initiated audits. The agency will also be investing additional resources to speed completions of audits for payment years 2024 going back to 2018 [8].
CMS announced the public meeting agenda for the 2025 Healthcare Common Procedure Coding System. The meeting was available in-person and virtually, taking place on June 2, 2025. The event featured speaker presentations and an opportunity for questions, including those pertaining to medical coding in USA [9]. Replays are archived on the CMS website.
The Department of Health and Human Services has proposed that oversight of the 340B drug pricing program fall under CMS as a component of reorganization plans. It would fall under the agency’s Program Management authority [10]. This change could impact hospital accounts receivable.
[1] CMS, “HPMS Memos for WK 5 May 26-30,” 30 May 2025. Available: https://www.cms.gov/about-cms/information-systems/hpms/hpms-memos-archive-weekly/hpms-memos-wk-5-may-26-30.
[2] CMS, “Medicare_Advantage_Prescription_Drug_System_June_2025_Payment,” June 2025. Available: https://www.cms.gov/node/2104336.
[3] CMS, “Medicare HETS 270/271 – Information Bulletin – Updated HETS Companion Guides – 6/2/2025,” 2 June 2025. Available: https://www.cms.gov/data-research/cms-information-technology/hipaa-eligibility-transaction-system/mcare-notifications/medicare-hets-270/271-information-bulletin-updated-hets-companion-guides-6/2/2025.
[4] CMS, “Innovation Insight: CMS Updates Accountable Care Model to Improve Model Sustainability,” 3 June 2025. Available: https://www.cms.gov/innovation-insight-cms-updates-accountable-care-model-improve-model-sustainability.
[5] CMS, “Shared Savings Program Application Types & Timeline,” 17 March 2025. Available: https://www.cms.gov/medicare/payment/fee-for-service-providers/shared-savings-program-ssp-acos/application-types-timeline.
[6] CMS, “HCPCS Quarterly Update,” 13 May 2025. Available: https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update.
[7] CMS, “Updated Hospital Price Transparency Guidance Implementing the President’s Executive Order “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information”,” 22 May 2025. Available: https://www.cms.gov/files/document/updated-hpt-guidance-encoding-allowed-amounts.pdf.
[8] CMS, “CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits,” 21 May 2025. Available: https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits.
[9] CMS, “Centers for Medicare & Medicaid Services’ (CMS’) First Biannual 2025 Healthcare Common Procedure Coding System (HCPCS) Public Meeting Agenda,” 2 June 2025. Available: https://www.cms.gov/files/document/b1-2025-public-meeting-agenda-june-2-2025-updated-05/19/2025.pdf.
[10] A. Murphy, “HHS proposes transferring 340B oversight to CMS,” Becker’s Healthcare, 2 June 2025. Available: https://www.beckershospitalreview.com/pharmacy/hhs-proposes-transferring-340b-oversight-to-cms/.
HCC risk adjustment in 2025 is more than just a compliance checkbox – it’s a strategic driver of revenue and regulatory resilience. With the Centers for Medicare & Medicaid Services’ (CMS) hybrid model blending the 2020 and 2024 HCC frameworks, risk adjustment medical coders, compliance teams, and clinical leaders are navigating a landscape where outdated codes vanish, specificity is king, and audits loom large.
But with the right tools and techniques, this complexity becomes opportunity.
The Centers for Medicare & Medicaid Services’ (CMS) CY 2026 Rate Announcement introduces significant updates that directly impact medical coding risk adjustment, revenue cycle operations, and overall reimbursement strategy. As healthcare leaders evaluate their prospective risk adjustment strategies in light of these changes, understanding the
The healthcare revenue cycle is undergoing significant transformation, driven by evolving regulations, shifting payer policies, and increasing administrative burdens. For revenue cycle leaders, these changes present both challenges and opportunities, especially in optimizing medical billing accuracy and choosing a medical billing outsourcing company partner.
With the current administration promising more deregulation in
