October 2026 Newsletter

Understanding UnitedHealth’s AI Strategy from a Revenue Cycle Perspective

As UnitedHealth Group launches deeper into AI waters, Becker’s has provided insights into what this means for the healthcare revenue cycle. This article reviews points including how their AI products work, the impact on appeal cycles and medical billing, and its progress on planned prior authorization reforms [1]. 

What this means for rev cycle teams: Track how often payer determinations trigger appeals, and how long those appeals take, so you can spot patterns early and adjust documentation before denials stack up. Teams with pre-bill validation in place may be better prepared for payer-side automation with less rework.

Texas Health Resources Models Shift In Medical Billing Denials Review 

Texas Health Resources in Arlington is moving toward identification of large-scale payer patterns that can be resolved in bulk. This transition moves them away from reviewing denials individually. The goal is to shift the team's focus to trends and “large-scale appeal projects” [2].

What this means for rev cycle teams: Teams aiming for a similar shift can start by tagging every denial with payer, reason code, and service line, then reviewing the totals monthly to see which patterns repeat. That pattern tracking lays the groundwork for a Prevention Over Recovery approach, which can help reduce repeat denials and rework before any bulk appeal project begins.

Optometry Falls Under OIG Focus

The Office of the Inspector General has published findings that optometrists were improperly paid for high-level E/M services performed at nursing facilities. These included eye exams for residents with diabetes or who were at high risk for glaucoma, as well as treatment and diagnostic tests for residents dealing with age-related macular degeneration; those services do not, by themselves, justify high-level nursing facility E/M billing [3]. 

What this means for rev cycle teams: Practices that bill optometry services in nursing facilities should sample nursing facility E/M claims (99307–99310) and check level selection against documented medical decision-making or time, as applicable.

HCPCS Codes for Enforcement of Home Health Consolidated Billing

CMS has released changes to the non-routine supply code list. The changes impact home health agencies and suppliers and will be effective as of January 1, 2027. Billing staff will need to be informed of updates to the HH CB non-routine supply code list, including removal of codes A4453 and A4459 [4]. 

What this means for rev cycle teams working with medical coding services: Update claim edits and supply billing rules before January 1, 2027, so A4453 and A4459 follow updated consolidated billing rules. Brief both agency billing staff and supplier contacts so neither side bills against the outdated list.

HETS User Eligibility Check Deadline

CMS is advising users of the HIPAA Eligibility Transaction System 270/271 to check that the email address on HETS EDI enrollment is correct. Action needs to be taken by December 1, 2026 and applies if users check eligibility through a billing company, EHR, software vendor, PMS, or EDI clearinghouse. Three consecutive monthly email delivery failures can suspend enrollment and disrupt eligibility checks [5].

What this means for rev cycle teams: Ask your clearinghouse, PMS, or billing company to confirm the HETS enrollment email before December 1, 2026, and assign one person to own that verification. If the address needs correction, the provider or supplier must update it through its Medicare Administrative Contractor (MAC); vendors cannot make that change for them.

CMS Finalizes Transparency in Coverage Final Rule

CMS has finalized amendments to the Transparency in Coverage rules (CMS-9882-F) to make plan pricing disclosures more accessible and standardized. The update builds on the 2020 rules requiring health plans and issuers to publish machine-readable files for in-network rates and out-of-network allowed amounts. The new rule also changes the posting cadence for these files from monthly to quarterly once applicable; prescription drug pricing file requirements have separate implementation considerations [6]. 

What this means for physician revenue cycle management teams: Physician groups can compare published in-network files before their next payer contract negotiation. Plans should test their machine-readable files against the new standardization requirements well ahead of enforcement.

OIG Audits Estimate More Than $202 Million in MA Overpayments

OIG performed three audits of Medicare Advantage contracts under Humana and UnitedHealthcare. The agency estimated more than $202 million in overpayments tied to diagnosis codes not supported by reviewed medical records. The two companies have disputed some findings and recommendations; these estimates are not final repayment determinations [7]. 

What this means for rev cycle teams: MA plans should confirm medical record support for every submitted HCC before RADV reviews reach them. Risk-based chart reviews and complete medical-record support can help address documentation gaps and audit exposure.

GLOBE Model Released

CMS has announced the release of the final rule for the Global Benchmark for Efficient Drug Pricing (GLOBE) model. The model is mandatory for selected drug manufacturers and assesses rebates for specific drugs that are payable under Original Medicare Part B when prices are higher than what is paid in countries that are economically comparable. The model begins January 1, 2027, and reduced coinsurance for eligible beneficiaries and drugs starts April 1, 2027 [8].

What this means for rev cycle teams: Practices with high medical billing Part B drug volume, such as oncology, rheumatology, and ophthalmology, should track CMS guidance on GLOBE’s effect on beneficiary coinsurance. Update eligible patients’ cost estimates as CMS clarifies the affected drugs and applicable guidance.

Implementation of Sections 6219, 6220, and 6224 of the Consolidated Appropriations Act

CMS issued a proposed rule to implement sections of the Consolidated Appropriations Act of 2026, including the REAL Health Providers Act (section 6220), which requires accurate provider directories, and new pharmacy benefit manager accountability requirements (section 6224). The rule also proposes a conforming change under section 6219 that would drop the Part D generic drug copay from $1 to $0 for full-benefit dual-eligible individuals. The proposed directory requirements begin in contract year 2028; the proposed Part D copay change also takes effect in 2028 [9].

What this means for rev cycle teams: Physician groups should audit the directory data they send to MA plans, including addresses, specialties, and new-patient status, since the REAL Health Providers Act raises the accuracy bar. Plans should build a recurring verification cycle with their networks before the rule finalizes.

Patients Confronting Payer CEOs with Medical Billing Denials

MedPage Today is reporting that some patients are taking insurance coverage disputes directly to the CEOs of health insurers. This has included emailing a CEO and sending an 11-page appeal to another CEO while copying lawmakers, journalists, and other executives. These cases illustrate individual experiences, not a substitute for formal appeals [10].

What this means for rev cycle teams: Give patients the specific denial reason and their appeal steps in the first communication after a denial. Clear explanations early help patients navigate the formal appeals process rather than relying on executive escalation.