November 2025 Newsletter

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.   

CMS Releases CY 2026 Payment Policies Under Physician Fee Schedule

The agency has released the final rule for CY 2026, addressing changes to the physician fee schedule, relative value of services, other changes to Medicare Part B payment policies, and changes to the statute, among other medical billing topics [1].

CMS Lifts Claim Hold on PFS

The agency announced on October 21 that it instructed all MACs to lift a hold and start processing claims dated the 1st of October and later, if paid under the MPFS, FQHCs, or ground ambulance transport. Also included were USA medical billing holds on telehealth claims that are confirmed as behavioral health services [2].

New Drug Payment Model Announced by CMS

CMS has announced a new drug payment model and has issued a Request for Applications for drug manufacturers who might be interested in participating in the GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) [3]. This payment model could impact hospital revenue cycle management in the future. 

50 States Submit Applications for Rural Health Transformation Program

CMS has announced that all 50 states have submitted applications for the Rural Health Transformation Program. The application period ran from September 15 to November 5, 2025. Applications will now go through CMS review for compliance with requirements and completeness. Approved applications will be announced by December 31, 2025, and funding will be distributed over five years starting federal fiscal year 2026 [4].

Shared Saving Program Changes Announced

CMS has released the CY 2026 Medicare Physician Fee Schedule Final Rule, including changes to the Medicare Shared Savings Program for physician medical billing. The program includes 477 ACOs covering over 650,000 providers who care for over 11.2 million people under Traditional Medicare [5].

Final Guidance for Initial Price Applicability 2028 Released

CMS has released the final guidance for Initial Price Applicability for Year 2028. It applies to the third cycle of negotiations under the Medicare Drug Price Negotiation Program. It also incorporates policy refinements coming from public feedback, with an emphasis on improved transparency in this aspect of revenue cycle management services [6].

Dr. Oz Questioned on “Error-Riddled” Medicare Advantage Provider Directory

Senators Jeff Merkley, D-Ore., and Ron Wyden, D-Ore. Issued a letter to CMS administrator Mehmet Oz, MD, questioning a “rushed launch” of the Medicare Advantage provider-directory tool. The November 4 letter expressed concerns that the tool, which intersects with physician medical billing, is “riddled with erroneous, conflicting, and duplicative information” [7].

UnitedHealth Group Predicts MA Enrollment Drop of 1 Million

UnitedHealth Group has projected Medicare Advantage enrollment would fall off by 1 million people next year, likely impacting the hospital revenue cycle. The original projection was for a decrease of 600,000 and has been adjusted since July [8].

Epic Guiding Government on EHR Comprehension

Judy Faulker, founder and CEO of Epic, has been addressing conversations with a congressman in preparation for a speech at HIMSS. She explained the issue of conflating interoperability with the EHR and outlined issues of government leaders not understanding how software in healthcare works [9] - a misunderstanding that likely extends to other healthcare revenue cycle solutions.