OK, as the old saying goes: Do you want the good news or the bad news first? And what can you do to maximize the good outcomes versus the bad ones?
On Saturday, March 15, President Donald Trump signed into law the hotly contested HR 1968, the full-year continuing resolution (CR) that funds the federal government through the end of September 2025.
The good news: The CR continues Medicare telehealth waivers and the hospital-at-home program through the end of the fiscal year ending Sept 30. Coverage remains in its current form for Medicare telehealth visits, expanded during the height of the COVID-19 pandemic. That coverage had been seen at risk, which would have negatively impacted short-staffed providers’ ability to see more patients, more efficiently, and enabling rural and less-mobile patients to receive healthcare services more effectively. A renewal of add-on payments for rural and “super-rural” ambulance services were also included through Oct. 1, 2025.
The legislation signed into law does renew a boost to the Medicare work geographic practice cost index, which benefits rural physicians. It also delays eliminating Medicaid Disproportion Share Hospital (DSH) payments for some more than 2,500 safety-net hospitals through Sept. 30, which were set to be eliminated starting April 1. Even then, it could still cause a loss of $8 billion of reductions annually in each of the fiscal years from FY26 through FY28.
The bad news: The legislation does not, however, include provisions to address a 2.83% cut to Medicare physician reimbursement, making a bad situation worse for the over 1.8 million providers who serve a total of more than 67 million Medicare patients in a time of provider shortages, higher provider costs and an aging U.S. population.
According to the Bruce Scott, MD, president of the American Medical Association, this legislation “locks in a devastating fifth consecutive year of Medicare cuts.” When adjusted for inflation, Medicare payment to physician practices has dropped 33% since 2000, the AMA noting that further cuts will force more practices to scale back services or close, particularly in rural areas.
The (partial) solution: Integrated, proactive denial avoidance
No matter what the financial formula is for reimbursement, an efficient revenue cycle management process is mission-critical to speed and maximize appropriate reimbursements from Medicare, Medicaid and private insurers. Using an integrated front- to back-office solution, it has become essential to file cleanly coded claims absolutely ASAP. With payer denials on the rise (an average of $5 million per provider, with the AMA reporting that 30% of physicians reported they have seen an increase in denials the past year), it’s essential to avoid…well…avoidable denials.
Most denials are blamed for a lack of prior authorization or referral. This is why Advantum Health provides not “only” billing services, but also end-to-end, advanced and proprietary technology-supported RCM team that delivers:
- Quality-controlled medical billing and coding
- Proactive denial management and prevention
- Automated provider enrollment and credentialing
- Seamless prior authorization and accurate eligibility verification.
- An 2024 AMA survey reported that 29% of participants reported that prior authorization has resulted in a serious adverse clinical event, and over 90% stated that prior authorization, if not done correctly, negatively impacts patient clinical outcomes and delays in care. A total of 80% said that prior authorization delays or denials negatively impact patient out-of-pocket costs, and provider reimbursements.
- Quality-controlled billing
- CMS-compliant auditing to optimize risk management
- Focused Accounts Receivable follow-up
The future
In an environment even more volatile than ever before, it’s difficult to say what the future will hold for U.S. healthcare providers and patients alike. But what can be assured is that an integrated and proactive denial-prevention and management system helps optimize and speed appropriate provider reimbursements, reduce denials and improve both the efficiency and positive clinical, administrative and financial outcomes of an increasingly short-staffed provider base and its aging patient population.
For more information on how Advantum Health’s experienced team and its proprietary technology-based,, end-to-end solutions can help, please contact us.
