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October 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 to the challenges of USA medical billing.

Home Health Industry Threatened by Shutdown

The recent government shutdown is causing problems for the home health industry and home health care billing, pushing it over a telehealth cliff, limiting its patient pool, and adding administrative burden, according to Home Healthcare News. It’s also frozen the Acute Hospital Care at Home (AHCAH) program [1].

Risk Adjustment Audit Overhaul Struck Down

A federal judge in Texas has ruled that DHS violated the Administrative Procedure Act, failing to appropriately notify industry stakeholders and the general public about the changes in the medical coding audit rule. The suit was brought by Humana, challenging the September 2023 RADV overhaul. The ruling is being counted as a significant win for payers [2].

CMS Expects Medicare Advantage and Medicare Prescriptions Drug Programs to Remain Stable

The agency has announced that the average plan choices, premiums, and benefits for the MA program and Part D prescription drug program will be stable in 2026. Average premiums are expected to decline in both programs. CMS is releasing this information ahead of Medicare Open Enrollment [3].

Lab Developed Test Final Rule Rescinded

The FDA rescinded the final rule on laboratory developed tests. This action puts a formal end to a long-term effort to increase oversight in the industry. The agency has issued a new final rule, changing the definition of in vitro diagnostics to align with pre-2024 regulations [4]. Healthcare providers and medical billing companies should keep an eye out for changes that impact them. 

HCPCS Quarterly File Updated

The previously released HCPCS quarterly update for October has been updated as of 9/23/2025. The medical billing updates can be reviewed and downloaded by the public on the CMS website under the file name: October 2025 Alpha-Numeric HCPCS File (ZIP) [5].

E/M Billing and Coding Updates Released by CMS

CMS has published a revised MLN booklet, covering E/M services. This update concerns billing and medical coding updates for home or residence services, telehealth services, hospital outpatient clinic visits, critical care services, and more [6].

The Impact of Federal Funding Cuts on Health Systems

Becker’s Hospital Review has published an overview of the impact of the One Big Beautiful Bill Act to multiple areas of healthcare including Medicaid reductions, ACA subsidies, Medicare Advantage, 340B drug pricing programs, and NIH funding [7].

New ICD-10-CM Codes Announced

CMS has announced new ICD-10-CM codes that are effective October 1, 2025 for revenue cycle management services. These codes will impact discharges from October 1, 2025 to September 30, 2026. They will also impact patient encounters between October 1, 2025 and September 30, 2026 [8].

Humana to Pay $32M in Fees in False Claims Settlement

Humana has been ordered by a federal court to pay over $32 million in fees, including attorney’s fees, costs, and interest connected with the resolution of a False Claims Act case from 2024. The lawsuit was filed in 2016 by a former actuary for Humana who claimed that the company sent CMS fraudulent bids for the Walmart Part D prescription drug plan [9].

The AHA Pursues Commitments on Prior Auth Reforms

The American Hospital Association has encouraged HHS leadership to keep the promises they’ve made on prior authorization reforms for the hospital revenue cycle. The association sent a letter to CMS and HHS leaders, emphasizing the fact that 95% of hospitals report that staff time spent on prior auth approval has increased in the last year, increasing patient frustration and burden on providers [10].

New Epic Interoperability Features

Epic has launched multiple new data-sharing features at a recent interoperability conference. They include more prior authorization APIs, MyChart changes, and updates to align with federal interoperability standards [11].

 

References

[1] M. Gonzales, “Government Shutdown Halts Telehealth Flexibilities, Hospital-at-Home Waiver, Threatening Home Health Industry,” Home Health Care News, 1 October 2025. Available: https://homehealthcarenews.com/2025/10/government-shutdown-halts-telehealth-flexibilities-hospital-at-home-waiver-threatening-home-health-industry/.
[2] P. Minemyer, “Federal judge strikes down 2023 risk adjustment audit overhaul in win for Medicare Advantage plans,” Fierce Healthcare, 26 September 2025. Available: https://www.fiercehealthcare.com/payers/federal-judge-strikes-down-2023-radv-audit-overhaul-win-medicare-advantage-plans.
[3] CMS, “Medicare Advantage and Medicare Prescription Drug Programs Expected to Remain Stable in 2026,” 26 September 2025. Available: https://www.cms.gov/newsroom/press-releases/medicare-advantage-medicare-prescription-drug-programs-expected-remain-stable-2026.
[4] S. Kelly, “FDA rescinds LDT final rule,” TechTarget, Inc., 19 September 2025. Available: https://www.medtechdive.com/news/FDA-rescinds-LDT-final-rule/760645/.
[5] CMS, “HCPCS Quarterly Update,” 23 September 2025. Available: https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update.
[6] CMS, “Evaluation and Management Services,” September 2025. Available: https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf.
[7] E. Cerutti, M. Ashley, J. Emerson and E. Casolo, “What ‘federal funding cuts’ really mean for health systems,” Beckers Hospital Review, 29 September 2025. Available: https://www.beckershospitalreview.com/finance/what-federal-funding-cuts-really-mean-for-health-systems/.
[8] CMS, “ICD-10 Codes,” 1 October 2025. Available: https://www.cms.gov/medicare/coding-billing/icd-10-codes.
[9] J. Emerson, “Court orders Humana to pay $32M in fees following False Claims settlement,” Beckers Payer, 30 September 2025. Available: https://www.beckerspayer.com/legal/court-orders-humana-to-pay-32m-in-fees-following-false-claims-case/.
[10] American Hospital Association, “AHA Supports Administration Facilitating Health Insurer Pledge to Reform Prior Authorization,” 29 September 2025. Available: https://www.aha.org/lettercomment/2025-09-29-aha-supports-administration-facilitating-health-insurer-pledge-reform-prior-authorization.
[11] G. Bruce, “Epic unveils new interoperability features: 7 things to know,” Beckers Hospital Review, 25 September 2025. Available: https://www.beckershospitalreview.com/healthcare-information-technology/ehrs/epic-unveils-new-interoperability-features-7-things-to-know/.

The ABCs of Laboratory Billing- How Pathology Groups Can Stop Losing Revenue
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The ABCs of Laboratory Billing: How Pathology Groups Can Stop Losing Revenue

Running a pathology group or diagnostic laboratory is challenging enough – but revenue cycle challenges make it even harder. If your lab claims are being denied due to missing prior authorizations, incorrect CPT codes, or “medical necessity not met” errors, you’re not alone. 

Laboratory billing is one of the most complex areas of U.S. healthcare revenue cycle management (RCM). With payers tightening scrutiny on molecular and genetic testing, expanding prior authorization requirements, and rolling

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September 2025 AI in Healthcare Revenue Cycle- The Big Opportunity in Medical Billing Accounts Receivable
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AI in Healthcare Revenue Cycle: The Big Opportunity in Medical Billing Accounts Receivable

A recent HFMA study shows that hospital CFOs see revenue cycle – especially medical billing accounts receivable and denials management – as the biggest area of opportunity for AI [1]. This raises a key question: what do revenue cycle leaders need to do to prepare? Considering the complexity of AI technology, choosing a good partner with “pre-AI” revenue cycle expertise is

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7 Best Practices for Medical Billing & Coding Services That Boost Revenue and Reduce Denials Image
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7 Best Practices for Medical Billing & Coding Services in 2025 to Boost Revenue and Reduce Denials

If you’re a U.S. healthcare provider searching for medical billing and coding services, you’re not alone. Thousands of physician practices, hospitals, and labs nationwide are rethinking how they manage revenue cycle operations – because missed modifiers, lost claims, and endless denials are draining revenue.

Medical billing and coding errors cost U.S. providers billions annually — not just in unpaid claims, but also in compliance risk, staff burnout, and unhappy patients. The good news? With the right blend of technology, process, and expertise, most of these issues are preventable.

Here are 7 proven best practices that top-performing practices, physician groups, and hospitals use to keep cash flow healthy, denials low, and compliance airtight.

1. Keep Your Medical Coding Guidelines Updated — Always

Billing and coding are constantly evolving. Every year, CMS, AMA, and commercial payers release updates to CPT, ICD-10, and HCPCS codes. Missing even one update can lead to underpayment or denials — especially in specialties with frequent coding changes like radiology, pathology, and behavioral health.

Best Practice:

  • Maintain a living medical coding manual updated quarterly.
  • Subscribe to payer alerts and CMS updates.
  • Use AI-powered medical coding tools to flag outdated codes before claims go out.

Pro Tip: U.S. practices that review coding guidelines regularly see 15-20% fewer denials related to coding errors.

2. Verify Patient Eligibility Upfront

One of the most common reasons for denials? Ineligible patients. Nothing is more frustrating than delivering care and discovering after the fact that coverage lapsed or prior authorization was required.

Best Practice:

  • Run real-time eligibility checks for every patient.
  • Verify coverage for high-cost procedures and check prior authorization requirements.
  • Document payer reps’ names and reference numbers when you confirm coverage.

Industry Insight: According to MGMA, eligibility issues account for nearly 27% of claim denials [1]. Catching them upfront saves you rework and write-offs.

3. Get Documentation Right the First Time

Clean documentation is the backbone of clean claims. If the diagnosis doesn’t support the CPT, or if signatures and dates are missing, your claim will end up in a denial queue.

Best Practice:

  • Use a documentation checklist that includes DOS, provider signature, and diagnosis-procedure match.
  • Standardize templates in your EHR for consistency.
  • Perform spot-checks on high-value procedures before submission.

Even a single missed modifier (like 25, 59, or 26/TC) can mean a $500+ revenue loss. Getting it right upfront pays off – literally.

4. Track Key Medical Billing KPIs Like a Hawk

You can’t improve what you don’t measure. Practices that monitor their revenue cycle KPIs consistently outperform those that don’t – and can intervene early when something goes wrong.

Best Practice: Track at least these core metrics:

  • Clean Claim Rate (Target: 95%+)
  • First Pass Resolution Rate
  • Days in AR (Target: < 35 days for most specialties)
  • Denial Rate by Category

Use a medical billing dashboard to visualize trends and take action before denials snowball into revenue leakage.

5. Perform Regular Coding Audits

Medical coding audits aren’t just for compliance – they’re for revenue protection. Undercoding costs you money, while overcoding can trigger audits and penalties.

Best Practice:

  • Conduct quarterly internal audits (retrospective + pre-bill).
  • Train your staff on findings so errors don’t repeat.
  • Use audits to identify missed units, unbilled add-on codes, and downcoded encounters.

Our experience shows that proactive audits can recover 3-7% of missed revenue without increasing patient volume.

6. Automate Medical Billing & Coding Workflows

Manual data entry, claim status chasing, and payment posting are productivity killers. The best U.S. practices are investing in automation and AI-driven RCM platforms to streamline processes.

Best Practice:

  • Leverage AI-assisted coding tools to reduce errors.
  • Automate claim status checks, payment posting, and denial routing.
  • Integrate your EHR, clearinghouse, and billing platform to eliminate duplicate data entry.

Providers using automation report 20–30% faster reimbursement cycles and lower staff workload.

7. Train & Upskill Your Team Continuously

The medical billing and coding landscape changes fast – and a one-time training isn’t enough.

Best Practice:

  • Host quarterly lunch-and-learns on payer changes.
  • Encourage coders to maintain AAPC or AHIMA certifications.
  • Provide feedback loops: share audit findings and celebrate improvements.

The Bottom Line: Best Practices Pay for Themselves

Implementing these best practices doesn’t just clean up your healthcare revenue cycle, it also improves compliance, reduces staff burnout, and keeps patients happier. 

But keeping up with payer changes, coding updates, and endless claim follow-ups can overwhelm even the best in-house teams.

That’s where RevGen-i, 3Gen’s AI-powered revenue cycle management platform, comes in. With RevGen-i, U.S. healthcare providers get:

  • Real-time eligibility verification to stop denials before they start
  • Intelligent analytics dashboards to track clean claim rates, denial categories, AR days
  • Workflow automation for claim status checks, payment posting, and follow-ups
  • Seamless integration with EHR and billing systems for a frictionless workflow

Together with our expert billing team, RevGen-i helps U.S. providers stay compliant, capture every dollar, and get paid faster, without adding staff or complexity.

Ready to see the difference? Schedule your free RCM assessment and see how much revenue you might be leaving on the table.

References

[1] MGMA, “6 keys to addressing denials in your medical practice’s revenue cycle,” 18 March 2021. Available: https://www.mgma.com/mgma-stats/6-keys-to-addressing-denials-in-your-medical-practice-s-revenue-cycle.

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