Revenue Cycle Management

AdvantEdge solutions include medical billing, certified coding, analytics,
practice management, compliance and ClientFirstTM service.

Revenue Cycle Management

AdvantEdge solutions include medical billing, certified coding, analytics, practice management, compliance and ClientFirstTM service.



Three Tips to Minimizing Radiology Claim Denials

Although claim denials are an inevitable reality in radiology (and in every specialty), there are steps you can take to minimize dreaded claim denials that eat up time, money, and energy. Read our latest blog post to learn three core practices that you can put in place today that can help optimize cash flow and minimize billing costs.  Read More

Healthcare Roundup

CMS | 2 min read

Congress Renews Calls to Address Medicare Fee Schedule

Congress renewed its call to address the Medicare fee schedule, which will directly impact radiologist reimbursement, as well as the potential to cut a large portion of core clinical services. Read More

AHA | 2 min read

AHA’s New Plan to Respond to the Evolving Healthcare Industry

In this COVID pandemic context, the AHA released a three-year strategic plan to adjust priorities, meet immediate needs to respond to the pandemic and work on long-term strategies to advance health. Read More

Pain Management | 2 min read

CDC’s 2022 Draft Guidance on Pain Management & Opioid use

The CDC issued an updated draft of its Clinical Practice Guideline for Prescribing Opioids that includes new evidence research in the field of pain management. Read More

CMS | 1 min read

Six CMS Updates Impacting ASCs This Summer

Review six CMS updates impacting ACSs since January 1, including updates on COVID-19 at-home testing and the No Surprises Act (NSA). Read More

How Health Trends in 2021 Will Impact the Future of Medical Billing

Health Prime and AdvantEdge  interviewed members of the executive team to provide insight into the major healthcare trends and issues of 2021 – and how this will translate and play out going forward.


Practice Review Kit







5 Benefits to Outsourcing Your Medical Billing in 2022

Making sure your patients are given the time and attention they deserve is among the top priorities for providers in every specialty – and running an efficient in-house billing department can be a job by itself. Check out our latest blog post highlighting 5 reasons why outsourcing your medical billing can optimize your practice on numerous fronts.  Read More

Healthcare Roundup

Healthcare Workforce | 2 min read

Are We Going to Extreme Measures to Combat the Healthcare Labor Shortage?

$20k sign-on bonuses for nurses. Aggressive international talent recruitment. These are just a couple examples of how the healthcare field is dealing with the talent shortage. Learn more. Read More

HIPAA | 2 min read

Will There Be Any HIPAA Changes This 2022?

In December 2020, the Office for Civil Rights issued a proposal to modify the HIPAA Privacy Rule in 2021, to take effect in 2022. Learn what these proposed changes include. Read More

Surprise Billing | 2 min read

No Surprises Act – Medical Professionals Fighting Back

17 medical associations have filed an amicus brief supporting a legal challenge to the No Surprises Act, disputing the resolution process. Read More

CMS | 1 min read

CMS Directs Insurers to Cover At-home COVID Tests

Insurers must cover at least eight at-home COVID tests per covered individual starting on January 15, per a new directive from the Biden administration. Read More

How to Evaluate a Billing Company

For physician groups and hospitals seeking medical billing services, we describe six factors to evaluate when comparing companies.


Practice Review Kit




Medicare physician billing rates for 2022 are now finalized with Congress over ruling most of the 9.75% cut proposed by CMS. See “Physician Billing in 2022: 10% Medicare Cut” for the CMS proposal.

In addition, the CMS radiation oncology model and large cuts to the clinical lab fee schedule were postponed by one year (see below).

Congress Overrules CMS Medicare Cuts 

The “Protecting Medicare and American Farmers from Sequester Cuts Act,” passed by Congress last week and just signed by the President, does the following

  • Postpones the 4% “PayGo” cut for one year.
  • Reinstates 3% of the Covid-driven 3.75% rate increase.
  • Delays the 2% sequester cut until July, with a 1% cut in the second quarter.

As a result, the headline 9.75% cut in the CMS proposal is now reduced to 2% spread unevenly across 2022

  • A .75% cut in the first quarter.
  • A 1.75% cut in the second quarter.
  • A 2.75% cut in the second half of the year.

Of course, these macro adjustments do not reflect specialty specific Medicare fee schedule adjustments. As an example, RBMA estimates the cuts  will now be about 3% for diagnostic radiology, and higher for interventional radiology.

While medical associations all cheered the legislation, they also pointed out the need for reform of Medicare rates to avoid the annual need for Congressional action. For example, Howard Fleishon, chair of ACR’s Board of Chancellors, said in a statement, “… we must begin to look beyond these short-term fixes. The ACR looks forward to working with Congress to address the ongoing structural problems associated with Medicare’s broken payment system.”

The American Medical Association (AMA) and others issued similar statements. “There is no need to wait for the last minute to start working on the systemic problems,” said AMA president Gerald Harmon, MD.” These automatic cuts should remind members of the needed reforms. Congress can get a head start on doing the right thing when it reconvenes early next year.”

CMS Radiation Oncology Model Delayed

The CMS Radiation Oncology (RO) project is intended to make site-neutral payments for certain radiation services. That model had already been delayed by a year and is now postponed until January 2023. The CMS RO model reduces reimbursement through bundling radiation therapy payments rather than paying for individual treatment episodes.

Oncology groups have warned that the mandatory model will lead to harmful cuts to radiation oncologists. 

Clinical Lab Rate Cuts Postponed

Proposed payment cuts to the Clinical Laboratory Fee Schedule (CLFS) were postponed by one year, much as they were for 2021. A group of 22 lawmakers had recently written to House leadership pushing for a delay to the cuts, which were required under budget neutrality rules..

The American Clinical Laboratory Association (ACLA) and another 27 health organizations recently sent a letter to congressional leaders saying that the “harmful” cuts — 15% for some 600 common clinical lab tests and up to 23%— would negatively impact lab services that are “essential to the health and wellbeing” of millions of Americans who have chronic diseases, particularly seniors.

Final Medicare Physician Billing Rates for 2022 References




Fix “Holes” in Your Physician Billing

In this blog post, we describe how to fix “holes” in your physician billing. It is well known that physician billing is a complex process. Less well known are the many “holes” in the process where money can disappear. This two-part Money Matters series starts with four ways to fix “holes” in your physician billing with techniques and capabilities that plug physician billing holes and help providers collect all monies due for each service provided.  Read More

Healthcare Roundup

Healthcare | 3 min read

Will Your Payer Mix Change in 2022?

Has your payer mix changed? In 2020? In 2021? Learn more about current health insurance dynamics and the factors that can affect your payer mix in 2022. Read More

CMS | 2 min read

Medicare Final Rule for 2022: 10% Physician Billing Cut!

The 2022 Medicare Physician Fee Schedule has a 9.75% physician reimbursement cut, expansion of telehealth and updates to the Quality Payment Program / MIPS. Read More

Radiology | 2 min read

Radiology Billing 2022: Positive and Negative

Low Dose CT expansion and more PET scans are two of several positives for radiology in 2022, despite other fee reductions. Read about these, new AUC criteria and more. Read More

OON | 3 min read

No Surprises Impacts All Physicians in 2022!

The No Surprises Act requires action by every practice by Jan. 1! While OON billing is affected most, notice requirements and cost estimates for self-pay apply to all. Learn what “No Surprises” means for your practice. Read More

How to Evaluate a Medical Billing Company

For physician groups and hospitals seeking medical billing services, we describe six factors to evaluate when comparing companies.


Practice Review Kit




Have you noticed changes in your medical billing payer mix? Covid dislocations affected most practices in 2020. But since then, the impacts have been modest on a nationwide basis. However, some practices and hospitals have seen more dramatic impacts. 

To see what changes are likely in 2022, let’s start with a picture of where Americans are getting their health insurance in 2021.

medical billing payer mix
(click image to enlarge)

Several factors drove this distribution. 

  • In 2020, the loss of employer coverage as employees were laid off, estimated at two to three million.
  • Offset by (larger) increases in Medicaid and ACA exchange enrollment
  • In 2021, ACA and Medicaid enrollment has continued to grow

2022 At a Glance

  • Commercial insurers are aggressively pushing Medicare Advantage plans and expect to take an ever-larger share of Medicare patients, despite concerns about the cost to the federal government.
  • The subsidies driving up Medicaid and ACA enrollment will continue, at least through 2022.
  • ACA exchanges have significantly more plan choices, a longer enrollment period and more assistance available.
  • A large number of uninsured are eligible for Medicaid or Exchange plans.
  • Commercial insurers are pushing telehealth options for 2022
  • The effects of the labor shortage may start to show up with more employees having coverage and/or better coverage

How each of these dynamics affects your medical billing payer mix in 2022 depends on your local conditions (more or fewer uninsured, Medicaid expansion state or not, etc.). Understanding the health insurance dynamics can help your practice get ready for 2022.

Employer provided health plans in 2022

Trends in employer provided insurance are expected to continue in 2022: somewhat higher employee premiums, cost-sharing and deductibles. As KFF explains in its recent report,

  • On average, covered workers contribute 17% of the premium for single coverage and 28% of the premium for family coverage. Covered workers in small firms on average contribute a higher percentage of the premium for family coverage than covered workers in large firms (24% vs. 37%). Covered workers in firms with a relatively large share of lower-wage workers have higher average contribution rates for family coverage than those in firms with a smaller share of lower-wage workers (35% vs. 27%).
  • Deductibles have increased in recent years due to both higher deductibles within plan types and higher enrollment in HDHP/SOs.

Family premiums for employer-sponsored health insurance rose 4% to average $22,221 in 2021, according to the 2021 benchmark KFF Employer Health Benefits Survey. On average, workers are contributing $5,969 toward the cost of family coverage, with employers paying the rest. The annual change in premiums roughly matches the year-to-year rise in workers’ wages (5%) and inflation (1.9%), though what workers and employers pay toward premiums over time has risen more quickly. Since 2011, average family premiums have increased 47%, more than wages (31%) or inflation (19%).

Fifty-eight percent of small firms and 99% of large firms offer health benefits to at least some of their workers, with an overall offer rate of 59%. 

The pandemic has introduced new factors that may eventually have impacts. As KFF says in the introduction to its new report on Employer Provided insurance,

  • “Whether and how employers structure benefits to support a potentially more far-flung workforce will be an important topic for the next few years. Similarly, it remains to be seen whether telemedicine will continue to grow as a source of access to care, or fade back to a more specialized option that is primarily available in difficult situations and hard to reach locations.”

Some insurers are aggressively expanding their telehealth options.

  • Starting in January, Cigna employer plans will have access to MDLive’s network for virtual primary care providers for routine care, sick visits, prescription refills or any needed follow-up care after a wellness visit.
  • Cigna is also launching virtual-first health plans to select employers in 2022. The plans, which will initially be available to large, self-insured employers, include a $0 co-pay for access to MDLive primary care providers, chronic condition management and care navigation.
  • UnitedHealth plans to roll out a virtual-first primary care product by the end of this year, combining its Optum physician network with payer UnitedHealthcare’s network offerings. 

A “wildcard” factor that will affect companies and your medical billing payer mix in 2022 is the labor shortage, which has led to enhanced benefits for both retention and recruiting purposes.  In the longer run, more employers are expected to offer healthcare and to a broader population. In the shorter term, i.e. 2022 employer plans are likely to be similar to 2021, but with more participants, especially in communities where the labor shortage is most acute.

Medicaid in 2022

CMS data shows that Medicaid enrollment grew by more than 11 million people — a 16% increase — from February 2020 to April 2021, supported in part by more flexible regulations during the pandemic. That momentum appears to have continued partly due to a more substantial special enrollment period in the spring and summer of this year. 

As a result, the number of uninsured American’s has been stable to decreasing during 2021. That is good news for hospitals and practices that serve these populations, especially those in rural areas. On the other hand, it is worth noting that the uninsured rate is almost double the national rate in those states that have not expanded Medicaid.  

As part of the Families First Coronavirus Response Act passed in March, states are receiving a 6.2% increase in the federal Medicaid match rate. In exchange, states are not allowed to disenroll any beneficiaries from Medicaid during the Public Health Emergency (PHE). 

So a key factor for Medicaid in 2022 will be when the PHE (currently due to expire on January 16) is allowed to expire.

ACA Healthcare Exchanges in 2022

ACA enrollment has also continued its momentum in 2021, with HHS reporting that 2.1 million people signed up for ACA coverage on (used in 35 states), during the special enrollment period from Feb. 15 to Aug. 15. The 15 state-run exchanges signed up 738,000 people. Six states and the District of Columbia are continuing their special enrollment periods through the rest of 2021.

Expanded income-based subsidies in the American Rescue Plan Act have made plans much more attractive to low income individuals and families.

Since these subsidies will continue through 2022, most observers expect to see increases in ACA enrollment. Especially considering that open enrollment is extended by an additional 30 days, the administration quadrupled the number of assistants helping consumers navigate the enrollment process and relaunched a program partnering with community organizations to provide outreach and education about the marketplace.

  • “This time around, the millions of marketplace shoppers can generally expect lower premiums, more choice in health plans and more robust subsidies that will reduce costs — at least for next year, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation who studies health care reform.” (NY Times)

Many Uninsured Eligible for Medicaid or Exchange Plans

According to KFF, a majority of people who remained uninsured in 2020 are eligible for financial assistance for coverage either through Medicaid/CHIP or the Marketplace. 

(click image to enlarge)

Traditional Medicare in 2022

Little change except for ongoing rate tweaks in favor of primary care at the expense of specialists. Of course, the downward revision to overall rates in the CMS Final Rule has many physicians concerned. Intense lobbying is hoped to convince Congress to reduce these impacts; see this article.  

Medicare Advantage in 2022

More than 26 million people are currently in Medicare Advantage plans, mostly HMOs and PPOs from commercial insurers paid to provide Medicare benefits to enrollees. This represents 42 percent of all Medicare enrollees. MA enrollment has doubled in the last ten years.

Per KFF, a record 3,834 Medicare Advantage plans will be available for 2022. That’s an increase of 8 percent from 2021, and the largest number of plans available in more than a decade.

  • “In 2022, a typical beneficiary will have 39 plans to choose from in their local market. But the number of Medicare Advantage plans available varies greatly across the country, with an average of 42 plans in metropolitan areas and 25 plans in non-metropolitan areas. In 2022, 25 percent of beneficiaries live in a county where they can choose among 50 Medicare Advantage plans.”

Medicare Advantage enrollment is concentrated in plans operated by UnitedHealthcare, Humana, and Blue Cross Blue Shield affiliates.

It should be noted that Medicare Advantage is not without its detractors, including claims that insurers are gaming risk adjustment practices to inflate profits. A series of recent articles in Health Affairs by former acting CMS Administrator Don Berwick and former Trinity Health CEO Richard Gilfillan sheds light on coding practices that have made the MA space extremely lucrative for insurers. But industry advocates counter that the criticisms are unfair and that patients get better care in MA plans compared to traditional Medicare. One study estimates overpayments to commercial insurers providing MA plans at over $100 million from 2010 to 2019 including $34 billion in 2018 and 2019 alone. 


Physician billing rates for 2022 are now official with publication of the Medicare Physician Fee Schedule Final Rule. It includes

Physician Billing Cuts

Despite protests from virtually every major physician organization and thousands of letters, the Final Medicare Physician Fee Schedule has very few changes from the earlier interim Final Rule (see A 10% Cut to 2022 Physician Reimbursement?). As a result, the 9.75% cut to Medicare physician billing in 2022 remains in place. Intense lobbying of Congress is underway, but no action is expected until late December, at the earliest. Some observers expect partial help from Congress, while others are less sanguine.

As a reminder, the cuts include

  • a 4% reduction from the PAYGO law, which calls for Congress to make a series of cuts if federal spending reaches a certain threshold.
  • Elimination of the temporary 3.75% 2020 increase in the Conversion Factor to help physicians combat revenue shortfalls caused by the pandemic. The 2021 CF is $33.59, a decrease of $1.31 from the 2021 rate of $34.89.
  • A 2% cut in Medicare under sequestration.

It should be noted that the fee schedule is required to be budget neutral under law.

Recently, Reps. Ami Bera, MD, D-Calif., and Larry Bucshon, MD, R-Ind., introduced the Supporting Medicare Providers Act of 2021 to prevent the 3.75% CF cut.

A recent survey of 2,227 members from the American College of Surgeons by the Surgical Care Coalition, a collection of 13 advocacy groups, found that 57% of respondents believe the cuts to physician billing in 2022 would lead to longer wait times, while 56% believe the cuts could contribute to a delay in care.

The pay cut serves as a “reminder of the financial peril facing physician practices at the end of the year,” American Medical Association President Gerald Harmon, MD, said in a Nov. 3 news release. The AMA has urged Congress to avert this cut to the conversion factor as well as cuts to Medicare physician payments overall, which add up to a combined 9.75 percent reimbursement decrease in 2022.

“This comes at a time when physician practices are still recovering [from] the personal and financial impacts of the COVID public health emergency,” Dr. Harmon said. “Congress is beginning to recognize that this financial instability could limit healthcare access for Medicare patients. The clock is ticking.”

Other Impacts

Updates to clinical labor rates are expected to increase payments to primary care specialists, such as family practice, geriatrics, and internal medicine specialties. But many other specialists, including radiology, radiation oncology and others will see decreases (see Will Radiology Reimbursement be Slashed in 2022?). 

Telehealth Services

The Medicare final rule allows certain services, such as cardiac and cardiac rehabilitation to remain on the telehealth list through 2023 to give stakeholders more time to evaluate if they should be permanently added.

CMS also removed geographic restrictions for providers to offer mental health services via telehealth.

Original telehealth regulations required an in-person physician visit six months prior to the initial telehealth service for mental health. The final rule waives that requirement under certain circumstances and requires an in-person visit at least every 12 months.

CMS will also allow reimbursement for audio-only telehealth services for the treatment of mental health disorders. But only if the patient is not capable of making a video call. Also, rural health clinics and health centers can now furnish mental health services via “interactive real-time telecommunications technology.”

There is also a requirement to use a new modifier for services using audio-only communications, which will verify that the practitioner had the capability to provide two-way, audio/video technology, but instead, used audio-only technology due to patient choice or limitations.

Quality Payment Program/MIPS

Transition to the Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs) will not occur until the 2023 performance year.

  • The seven MVPs for the 2023 performance year are: rheumatology, stroke care and prevention, heart disease, chronic disease management, emergency medicine, lower extremity joint repair and anesthesia.
  • MIPS eligible clinicians can report the APM Performance Pathway as a subgroup, beginning with the 2023 performance year.
  • The performance threshold for the 2022 performance year/2024 payment year will be 75 points, an increase of 15 points.
  • The additional performance threshold will be set at 89 points.
  • For individuals, groups, and virtual groups reporting traditional MIPS, quality will be weighted at 30%, cost at 30%, interoperability at 25% and improvement activities at 15%.
  • The CMS Web Interface will be a quality reporting option for registered groups, virtual groups or other APM Entities for the 2022 performance period.
  • The 70% data completeness requirement will be retained for the 2023 performance period.


The “No Surprises” Act impacts all physicians in 2022! Obviously, there are big changes for out-of-network (OON) billing. But all practices and departments need to get ready quickly as these requirements go into effect January 1, 2022:

  • All providers, even those fully in-network, must publish and publicize information about the No Surprises Act.
  • Almost all out-of-network billing reimbursement and patient billing will be required to change. 
  • Any referrals or scheduled procedures for self-pay or uninsured patients will require a good-faith cost estimate.
  • Billing must consider state as well as federal “No Surprises” legislation.

Setting aside the current debate about how disputes should be settled (see “No Surprises” Act, Physicians Lose), here is why the No Surprises Impacts all Physicians, starting in January. 

First, we should note that the federal No Surprises rules apply to

  • All out-of-network emergency services,
    • Including post-stabilization care at out-of-network facilities until a patient can be safely transferred to a different facility,
  • All air ambulance transports, 
  • All non-emergency out-of-network services delivered at or ordered from an in-network facility, unless the provider follows the notice and consent process.
    • All care during such a visit by any provider is limited to in-network cost sharing, unless notice and consent criteria are met (see below).

In other words, the new rules apply to the vast majority of OON billing situations. The only exception appears to be services delivered at an OON facility. 

It’s also worth noting that payers can no longer second-guess payment for emergency treatment. Emergency services are required to be covered

  • Without prior authorization.
  • Regardless of whether the provider is an in-network provider or an in-network emergency facility.
  • Without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes.

Publish No Surprises Act Information

The first way that No Surprises Impacts all Physicians is that all providers are required to post a one-page notice with “information in clear and understandable language” on:

  1. The restrictions on providers and facilities regarding balance billing,
  2. Any applicable state law protections against balance billing, and
  3. How to contact appropriate state and federal agencies when an individual believes that a provider or facility has violated the restrictions against balance billing.

A model notice that providers can use, if they wish, is available from CMS here.

Out of Network Billing: Adding Complexity for Providers

According to Experian Health, 

“Creating a “no surprises” billing experience will require payers and providers to make major process changes. Roger Johnson, VP of Payer Solutions at Experian Health, says, “The new regulations require the industry to innovate significantly in a very short timeframe. Determining network status is a huge challenge for providers, as is engaging patients electronically pre-service. There will also be challenges in tracking and submitting consent forms, producing Good Faith Estimates, applying appropriate cost-sharing, billing, payment reconciliation, and the new dispute resolution process.”

One major challenge for physician billing will be determining the patient portion to be billed. Fortunately, much of the information needed for the patient portion is supposed to be provided on updated insurance cards.

  • The No Surprises Act requires plans to include applicable deductibles, out-of-pocket maximums and contact information on physical or electronic ID cards. However, CMS has not issues specific rules for this requirement and they aren’t expected until next year.
  • In the meantime, payers are required to use “methods that are reasonably designed and implemented” to provide the required information to all of their customers. CMS will consider
    • Is each specific data element on the card?
    • Are required data elements not included on the face of an ID card made available through information provided on the ID card?
    • What mode is used to provide information absent from the card?

As a result, in many cases, it may be possible to determine the patient responsible amount and issue a bill. For non-emergency situations, these amounts could potentially be collected in advance.

Of course, the larger issue is the amount that can be collected from the payer (insurance company). This is where controversy exists (see “No Surprises” Act, Physicians Lose). Under current rules, the OON payment rate is

  • Any State law or All-Payer Model Agreement mandated rate, 
  • The amount agreed by the parties or 
  • The lesser of the billed amount or the Qualified Payment Amount (QPA), unless the payer decides to pay a different amount.

The QPA is defined as the median of the contracted rates recognized by the health plan on January 31, 2019 for the same or similar item or service provided by a similar provider in the same geographic region, and indexed for inflation. That amount is to be paid within 30 days of receiving the bill.

As a result, while the physician can bill at a “normal” OON rate, the expected payment will typically be much lower. After an initial payment is received, the provider, if dissatisfied, can initiate a negotiation, starting a 30-day clock for the provider and insurer to settle. 

If there is no agreement after 30 days, the parties enter a “final offer” arbitration. Both sides submit their best offer and an arbitrator picks one. This is the “Independent Dispute Resolution (IDR)” process. 

If a provider starts the IDR process, both the provider and the health plan will submit a proposed payment to a CMS-approved arbitrator, along with information on the following factors:

  • The calculated QPA
  • The provider’s training and experience
  • The complexity of the procedure or medical decision-making
  • The patient’s acuity
  • The market share of the health plan, and the provider
  • Whether the care was provided at a teaching facility
  • The scope of services
  • Any demonstration of good faith efforts to agree on a payment amount; and
  • The contracted rates from the prior year

The arbitrator will then choose one of the two proposals as the amount of the payment. Under the current regulations, the arbitrator cannot come up with his or her own payment amount. Arbitrators are paid through fees assessed to the entities that use the IDR process.

Obviously, this is an onerous and expensive process, even it is undertaken to deal with multiple situations and payments (which appears to be possible though those procedures are not defined). The risk to OON providers (and the source of most of the recent controversy) is that the current No Surprises Interim Final Rules tell the arbitrator that the Qualified Payment Amount (QPA) is the most appropriate rate to consider!

Notice and Consent for OON Services and Billing

There is an exception for patients who wish to voluntarily use an out-of-network provider when a “substantive choice” exists. In this case, an OON provider must notify a patient of its OON status and get the patient’s written consent to receive OON services, at OON rates, at least 72 hours prior to the services, or 3 hours before for a same-day appointment. The consent form must indicate

  • Whether pre-authorization is required,
  • What in-network providers are available, and 
  • A good-faith cost estimate for the total bills for the proposed out-of-network care

While detailed rules on the consent process have not been published, it appears that OON consent can be on a provider-by-provider, or service-by-service basis. In the case where a service involves a number of OON providers, consent must be obtained for each. Or, if obtained on a service basis, the good-faith cost estimate must encompass all OON providers. 

Good Faith Estimates for Self-Pay and Uninsured

Starting in January, a provider must give an uninsured (or self-pay) patient a good faith estimate of expected charges after an item or service is scheduled, or upon request. Note that this is another case where the No Surprises Impacts all Physicians! This requirement applies to all providers and health care facilities, whether in network or not. In other words, every healthcare provider must be prepared to provide the good faith estimate upon request of any uninsured or self-pay patient, including those who choose to have a procedure done without submitting it to their insurance.

Here are the specific requirements:

  • Within 1 business day after scheduling (when service is scheduled at least 3 business days before the patient is seen) or 
  • No later than 3 business days after scheduling (when service is scheduled at least 10 business days before delivery), depending on scheduling; or
  • Within 3 business days after an uninsured (or self-pay) consumer requests a good faith estimate.

The good faith estimate should use clear and understandable language and include an itemized list of each item or service, grouped by provider or facility. Each item or service is to have details and the expected charge. A paper or electronic copy is to be provided, even if the information is communicated on the phone or verbally in-person.

For more, review our references for out of network billing.


Is 2022 Radiology Billing Impact: Positive and Negative? Really? As almost everyone knows, the Final Rule from CMS for the 2022 Medicare Physician Fee Schedule shows radiologists facing a 9.75% reimbursement cut unless Congress intervenes: see “Physician Billing in 2022: 10% Medicare cut!.

But there are also several positive factors in the Final Rule and other recent rulings

  • The clinical labor wage update is now phased in, reducing its impact by at least 50%
  • Penalties for Appropriate Use Criteria (AUC) have been postponed until at least 2023
  • Updated AUC criteria have been published
  • The FDA is finally moving ahead with rules for Clinical Decision Support systems (CDS)
  • Reimbursement for Low Dose CT for Lung Cancer screening has been increased. Coupled with expansion of the screening criteria, experts project an increase up to 60%
  • Restrictions on the use of PET scans will be removed in 2022

Clinical Labor Wage Update

“Despite objections from [the American College of Radiology] and others, CMS chose to move forward with implementation of clinical labor pricing updates,” the professional association said. “However, due to the actions of ACR and others, the updates will be phased in over a four-year period, and the payment impact to radiology and radiation oncology providers largely reduced by half.”

According to the ACR, these changes will decrease the initial estimated impact to diagnostic radiology and nuclear medicine from -2% to -1%, interventional radiology from -9% to -5% and radiation oncology from -5 to -1%. Of course, the impact on a specific practice will be determined by its mix of procedures.

Appropriate Use Criteria Penalties Postponed

CMS is postponing the penalty phase for the Appropriate Use Criteria (AUC) program to the later of January 1, 2023, or the January 1 that follows the declared end of the COVID public health emergency. This proposal (delayed for many years) requires physicians to consult a decision-support system (see below) before ordering advanced imaging. The rule would apply penalties to physicians who order advanced imaging services without clinical decision support based on AUC.

Updated Appropriate Use Criteria from ACR

The American College of Radiology recently published new imaging appropriateness criteria. The update includes five new topics and eight revisions to earlier ones. ACR initially published its influential criteria in 1993, with evidence-based guidelines to aid in selecting proper imaging exams and guided procedures. It now offers 216 topics spanning 2,400 clinical scenarios.

  • “ACR appropriateness criteria serve a vital role in helping to ensure that patients receive the necessary, quality care that they expect from their healthcare providers,” Mark Lockhart, MD, chair of the Committee on Appropriateness Criteria, said Oct. 11. “These criteria are recognized as the national standard in radiologic care.”

New topics include imaging of a child with suspected Crohn’s disease, facial trauma following a primary survey, axillary masses, newly diagnosed scrotal abnormalities, and pediatric musculoskeletal infections. The guidelines have color-coded categories of appropriateness, along with relative radiation levels for each exam.

The eight updates cover the range from staging of colorectal cancer to imaging after shoulder arthroplasty. Providers can consult the guidelines to meet their legal requirement (specified in the 2016 Protecting Access to Medicare Act) to consult appropriate-use criteria before ordering imaging. CMS has designated ACR as a qualified provider-led entity.

Clinical Decision Support (CDS)

One of the reasons for the delay in AUC enforcement (see above), has been the lack of approved CDS systems. Much of the industry has been waiting for the FDA to issue CDS guidelines. A first draft was published in 2017 and a revised draft in 2019. Both drafts received extensive comments from the industry, including from the American Medical Informatics Association, warning that guidance may leave “lingering confusion” about the regulatory status of software.

The FDA recently added clinical decision support as an “A-list priority” and now seems close to finalizing the guidance, including clarifying when CDS meets the definition of a medical device and a risk-based framework for the software functions.

Most observers are pleased that clinical decision support is finally an A-list priority, but disappointed that the guidelines have taken more than five years to get to this point. 

CT for Lung Cancer Screening

The combination of higher reimbursement and expanded guidelines for low dose CT screening for lung cancer has drawn cheers from the radiology community.

 In the 2022 Medicare Hospital Outpatient Prospective Payment System (HOPPS), CMS increased the reimbursement rate for hospital outpatient CT lung cancer screening. This is a positive for radiologists and for the ACR. For years, the ACR has pointed out the inadequate payments for low-dose CT for lung cancer screening for the disease for years. The new reimbursement rate will be $111.19, up 37.4% from the current rate of $80.90 (CPT code 71271).

  • “New U.S. Preventive Services Task Force guidelines have nearly doubled the number of people eligible for such screening,” the ACR said. “However, less than 15% of Americans who met previous USPSTF lung cancer screening criteria are tested. Improved payment may bolster lung cancer screening availability.”

In a recent JAMA Network Open, experts said that new lung cancer guidelines could generate up to a 54% increase in eligibility for low-dose CT screening, with significant gains in minority populations. Another recent study indicated that healthcare systems should plan to increase capacity by 50%-60% to help accommodate this new cohort of patients. This could include increasing the number of trained radiologists, CT scanners, and thoracic surgeons, the authors advised.

The influential U.S. Preventive Services Task Force (USPTSF) recently lowered the recommended starting age from 55 down to 50, among other changes. Along with dropping the smoking history from 30 to 20 pack-years, Kaiser Permanente researchers believe these modifications could produce a 30% uptick in lung cancer diagnoses when compared with previous recommendations. 

On November 17, CMS released a proposed updated to its screening guidelines to accommodate the USPTSF recommendations. The ACR immediately applauded the CMS proposal, with ACR Lung-RADS Committee chair Dr. Ella Kazerooni saying, “As lung cancer kills more people each year than breast, colon, and prostate cancers combined, this cost-effective exam is poised to save more lives than any cancer screening test in history. It is critical that physicians know of new guidelines so they can engage with patients to make informed screening decisions.” The ACR plan to comment on the proposed changes during the comment period which ends December 17. A final rule is expected by February 15 of next year.

PET scans

The Society of Nuclear Medicine and Molecular Imaging (SNMMI) has applauded a recent federal decision to lift longstanding restrictions on payment for PET scans.

This noncoverage determination dates to 2000, when CMS implemented broad, national restrictions on positron emission tomography (PET) scans outside of cancer care. SNMMI and others have lobbied against the change for more than ten years and were rewarded with the release of the 2022 physician fee schedule.

SNMMI President Richard Wahl, MD, said the decision opens a pathway for PET use in assessing cardiac, neurological, infectious, inflammatory and other conditions. “Removal of the exclusion will enable physicians to base their care decisions on using the right procedure for the right patient at the right time,” Wahl said in a Nov. 11 statement.

The change will take effect on January 1, 2022 and will allow Medicare Administrative Contractors to make decisions about payment for non-oncologic PET use “quickly and effectively.” SNMMI said it is now working with MACs to ensure the coverage rule is implemented properly. It also continues to advocate for the removal of similar noncoverage determinations related to amyloid and NaF PET.

2022 Radiology Billing Impact: Positive and Negative

To summarize, while the 2022 environment for radiology billing faces some challenges, there are also opportunities!


Company Refreshes Cornerstone White Papers “How to Evaluate a Billing Company” and “In-house vs a Medical Billing Company” 

WARREN, NJ – November 17, 2021 – AdvantEdge Healthcare Solutions (“AdvantEdge”), a leading national medical billing company with comprehensive coding, practice management and revenue cycle management services, today announced the refresh of two core white papers, “How to Evaluate a Billing Company” and “In-house vs. a Medical Billing Company.” Both have been instrumental in helping specialty physician groups improve medical billing results – and have recently been updated to reflect the latest industry trends.

Below is an overview of both white papers, as well as updates reflecting the current landscape.

  1. “How to Evaluate a Billing Company” – Six key factors are highlighted for physician groups and hospitals seeking medical billing services – Performance vs. Price, Reporting and Dashboards, Technology, Credentials, Compliance, and Security. In this updated version, Technology has been bolstered to explore the complexities in billing systems management and use of automated processes. Reporting and Dashboards also get added emphasis as they are key to reimbursements, customer satisfaction, and helping clients better understand their business in an actionable, proactive manner.
  1. “In-house vs. Medical Billing Company” – AdvantEdge provides a comprehensive framework to compare in-house billing vs. outsourcing or co-sourcing with a medical billing company. Along with outlining the overarching factors that impact this comparison – Financial Performance, Privacy and Security, and Cost – the white paper offers a detailed Appendix that can be used to compare service fees and costs involved with both in-house departments and medical billing companies. 

Companies are investing and putting concentrated efforts into improving digital security. Learn more about the importance of partnering with a medical billing company with deep security expertise, leading-edge technology, and the resources to minimize data breaches and other cybersecurity risks. Download our “5 Medical Billing Cybersecurity Questions to Ask” business brief for more. 

About AdvantEdge Healthcare Solutions
AdvantEdge, a member of the HealthPrime family of companies, is recognized as one of the top ten U.S. medical billing companies providing billing, certified coding, and practice management services to healthcare providers nationwide. Our services substantially improve decision making, maximize financial performance, streamline operations, and eliminate compliance risks for our healthcare clients. To learn more about AdvantEdge, visit our website at Follow us on Twitter at @DoctorBilling and on LinkedIn.




How to Get an A in Your Billing Practices

The strength of your billing process and its ability to “earn” all money due is driven by people, processes, and technology. Learn how assess your “grade” and see if all three are performing optimally. Plus: how you can  change your grade for the better! Read More

Healthcare Roundup

HHS | 2 min read

“No Surprises” Act Rule: Physicians Lose

HHS’ recent second interim final rule (IFR) generated universal, harsh reactions from physicians and hospitals. Read how the IFR will impact physician reimbursement. Read More

Radiology | 2 min read

Radiology Industry Fights to Curb 2022 Medicare Cuts

With Medicare’s proposed radiology cuts targeted for January 1, radiologists and their advocates are fighting for Congress to intervene while also bracing for sweeping changes to their practices. Read More

Pathology | 2 min read

How an EMR Helps Pathology Billing & Management

With the growing reliance on remote care in a post-pandemic environment, digital tools become more of a necessity for better accessibility and efficiency. Learn how EMRs can help pathology practice billing and management. Read More

Anesthesia | 1 min read

All Anesthesia Reimbursement Driven Down by Surprise Billing Law?

The “No Surprise Billing” IFR has raised alarms (see our first item).But a more insidious risk is lurking. In-network anesthesia reimbursement is likely to decline over time! Read More

5 Medical Billing Cybersecurity Questions to Ask

Download our business brief now for 5 essential cybersecurity questions to ask your medical billing department or your current/potential medical billing company.


Practice Review Kit




Will all anesthesia reimbursement be driven down by No Surprise Billing rules? Recent regulations to implement the “No Surprise Billing” act have raised alarms by “placing a thumb on the scale” to favor insurers. Without major changes, these rules may have a dramatic effect on out-of-network anesthesia reimbursement.

But a more insidious risk is lurking. In-network anesthesia reimbursement is likely to decline over time as anesthesia groups lose negotiating ground to commercial insurers. A recent JAMA Network study highlights and quantifies the risk. 

  • “The analysis found that prices paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists decreased in California, Florida, and New York after each state passed comprehensive surprise-billing legislation.”

The JAMA study analyzed more than 2.5 million claims filed for patients with private health insurance who received anesthesia services in hospital outpatient departments and ambulatory surgery centers from 2014 to 2017 in the three states with surprise billing legislation during that timeframe.

The study concluded that “State surprise-billing legislation appears to directly lower out-of-network prices and indirectly lower in-network prices by changing payer-practitioner negotiating dynamics.”

Since, on average, anesthesia rates exceed Medicare rates by 330%1, more than any other specialty, it seems logical to assume that commercial insurers will target anesthesia providers for reductions. Implementation of the No Surprises Act will reduce anesthesia provider negotiating ability in at least two ways

  1. Out of network rates are likely to be driven toward the median in-network rate, reducing out of network reimbursement. 
  2. During in network rate negotiations, the threat of a provider leaving an insurer’s network will be discounted.

These dynamics mean that anesthesia groups must be prepared to explain and defend their rates in compelling ways in order to minimize their effects on commercial reimbursement. Otherwise, all anesthesia reimbursement will be driven down.


1. [Commercial Health Insurance Markups over Medicare Prices for Physician Services Vary Widely by Specialty]

Ralph Waldo Emerson said it best: A good system shortens the road to the goal.” When it comes to ensuring that healthcare providers collect all money due, its essential to consider the strength of your entire billing process, including the people and technology(ies) employed to create and follow these processes.

After extensive research, AdvantEdge medical billing experts found that the best predictor of a practice or departments ability to collect all money due is the grade” earned by the current operations: the old idiom – people, processes and technology. If your current outcome isnt an  A, the good news is you can take action to improve. 

Medical Billing Grade: A  – Built to Last 

When we study operational and billing processes, we are looking for well-defined and executed processes that help ensure that providers leave little or no money on the table. When we say well-defined, were talking about written processes in a user-friendly format. These processes include training, job specifications, timing expectations, workflows, system specifications, exception and escalation procedures, performance reviews and other personnel policies.  Written processes and procedures alleviate ambiguity and allow employees and their managers to be aligned on what is required and expected of them – and how their job roles impact their colleagues.

Processes should encompass these functions:

  • Patient intake and scheduling (if applicable)
  • Referral and pre-authorization processes for specialists (if applicable)
  • Clinical and demographic capture, and related integrity testing and improvement
  • Coding and claims preparation
  • Claims submission
  • Claims follow-up and status reporting
  • Patient communications – Customer service expectations
  • Patient deductible, copay, and self pay processing and collections
  • Denial management reporting 
  • Payment posting
  • Contract management (is the practice getting paid according to its payer contracts)
  • Ongoing accounts receivable management
  • Reporting & analysis – Actionable metrics and leading indicators
  • Patient education

Its also important to have formal measurements in place for cycle times. For example, claims coded within 72 hours of clinical procedure performed, 96 percent of claims to be filed within 24 hours of coding, etc.  

Ongoing and open communication is an essential ingredient in the mix because this gives everyone on the team an opportunity to share ideas and suggestions about how to make the process even more efficient. For example: If a staff member observes that some insurance cards are not presented at the time of service, he or she can recommend that scheduling personnel collect insurance information in advance over the phone or online. If everyone on the team is encouraged to offer suggestions about how to best resolve issues, operations will continue to improve. All processes also need to be supported and reinforced by leadership. Note that highly skilled people can keep poorly defined processes afloat for a while, but this isnt sustainable. There is no substitute for well-defined processes with employees who believe in them and follow them. 

Medical Billing Grade B – People Power

A billing operation may have well-defined processes, but with employees not effectively executing them. This can happen if there is no clear understanding of why things are done a certain way, so the importance of following processes is not embraced. Or the problem may be in follow-through. A lack of interaction among functional groups can also be responsible  for billing inefficiencies. All of these issues are made worse when there is not enough skilled staff or there is excessive employee turnover. Operations that earn a B Grade are missing 5 to 15 percent of their potential collections. 

Medical Billing Grade C – Repairs Needed

If processes are not clearly defined or employees are unaware of how processes should work, then youre most likely in C territory. Once this has been determined, its wise to step back and formulate a new strategy. 

Boost Your Grade

If you are not earning an A, then you have strong financial (and potentially compliance) motivation to improve. You essentially have two choices:

  1. Invest time and money to improve your current operation: processes, people, technology.
  2. Hire an expert to do your billing; i.e. a professional medical billing company already operating with an A grade.

Option 1 requires a significant investment of practice leadership time, in addition to process, people and technology upgrades. A rule of thumb is that when something is broken, 80 percent is process and tools based, and 20 percent is people. Do you have the analytic skills to figure out what needs to be fixed? If not, a practice assessment by an expert firm is needed as a first step. Many practices significantly underestimate the effort required to get their billing operation up to par” and keep it there. Recent labor shortages and pay increases make it that much harder.

Option 2, on the other hand, can free up practice leadership time, while achieving top rank results. More and more practices and departments are turning to specialized medical billing companies to handle physician billing, including coding, charge entry, claims filing, payment posting, insurance follow-up, denial management, patient inquiry services, etc. Since these services are both difficult and expensive to maintain internally, it often makes sense to have them done by an expert billing company that can consistently maintain an A grade.  

Other factors to consider are:

  • Billing companies usually charge a percentage fee which directly links your billing costs with your bottom line financial performance. It also creates a meaningful incentive for those responsible for results to be motivated to achieve them.  
  • A medical billing company also empowers healthcare providers with more time to focus on what they do best – delivering exceptional healthcare. 

Want to learn more about how your practice can improve its medical billing grade? Get in touch with an AdvantEdge expert now, or stay up to date on company and industry trends by visiting our LinkedIn page. 

2022 Radiology reimbursement continues to be a hot topic. Last month, our article – “2022 Radiology Billing Changes” – described sweeping radiology pay cuts by Medicare if Congress fails to step in by January 1. 

While there is nothing official to report, there has been an avalanche of lobbying and letter writing including predictions for what could happen if the lower radiology billing rates go into effect. 

If Congress or CMS don’t fix 2022 radiology reimbursement, providers predict the closures of many radiology practices

  • Hundreds of radiologists and other physicians have flooded Washington with pleas to avoid massive Medicare cuts set to hit the specialty in a few months.
  • Many feel these cuts will deeply affect communities that have been especially hit hard by the COVID-19 pandemic.
  • Private practices may cut staff, reduce services or simply close.
  • Proposed cuts to physician reimbursement could shutter practices and leave thousands of medically vulnerable patients without access to care, according to a letter from The Society of Interventional Radiologists to CMS.
  • The American Society for Radiation Oncology estimates the specialty will absorb $300 million in Medicare cuts Jan. 1, which “will be devastating to cancer patients and radiation oncology teams, endanger patient access to life-saving treatment and threaten the viability of clinics still reeling from the COVID-19 pandemic.”

Practices will need to cut staff, freeze hiring and more

  • Several medical groups state that this round of cuts will derail their move to value-based care and impact hiring of new staff. 
  • According to new survey findings commissioned by the AMGA, nearly 43% of medical groups expect to freeze hiring and delay population health initiatives if the Medicare pay cuts go through. Another 37% admitted they would likely eliminate services, and 20% anticipate furloughing or laying off clinical staff.

Radiology groups are lobbying aggressively against 2022 radiology reimbursement cuts

  • The American College of Radiology® (ACR®) is the biggest radiology lobbying group. Efforts by its coalition of providers have led to signatures from more than half the members of Congress on a bipartisan letter to CMS, asking to stop the rate reductions. 
    • “If you have not done so already, tell your member of Congress to join U.S. Reps. Ami Bera, MD, and Larry Bucshon, MD, in urging congressional leaders to extend the 3.75% positive Medicare physician payment adjustment that is scheduled to expire Dec. 31.”
  • The Radiology Business Management Association has launched the Radiology Patient Action Network group to fight the $5B in pay cuts facing the radiology profession.
  • The AMGA is actively urging Congress to intervene, as well as to cancel the conversion factor decrease.

At this point in the radiology reimbursement conversation, it is far too early to predict which, if any, of the proposed cuts will be offset. Radiology practices and providers are faced with having to plan for a 2022 budget with significantly less Medicare reimbursement. Some practices will view this as a contingency plan; others as a baseline plan for 2022. In most cases, practices are likely to postpone as much investment and hiring as possible, until the outcome is known.



Society of Interventional Radiology Letter to CMS

American Society for Radiation Oncology Letter to CMS Advocacy 

Partnership Combines Practice Management and Revenue Cycle Management Solutions
and Services to Solve a Major Pain Point for Physicians

National Harbor, MD and Warren, NJ – October 22, 2021– Health Prime and AdvantEdge Healthcare Solutions, Inc., two leading practice management and revenue cycle management (RCM) solutions providers, today announced a strategic partnership of their businesses to alleviate the administrative burden imposed on physicians and healthcare providers. Offering the companies’ highly complementary solutions and services which are delivered to adjacent market segments, will allow both organizations to reach a broader network of healthcare providers and specialties.  

“AdvantEdge is an exciting and timely addition to our growing family of healthcare companies,” said Pranil Vadgama, CEO and President, Health Prime. “Each company provides expertise and a wide breadth of services and specialties. By bringing the companies together, we will provide a much stronger value proposition to our existing clients and new clients. AdvantEdge’s white-glove approach to customer service, performed locally, is a key competitive advantage that we are excited about leveraging which complements our own model. We are truly stronger together.”

Health Prime provides technology and resources to help optimize physician practice and surgery center operations. The company’s Datalytics business intelligence platform gives timely and actionable insights into the medical billing and collection process and full visibility into key performance metrics so practices can focus on changes that will have the most positive impact and be prepared for the reimbursement shifts associated with value-based care. 

AdvantEdge is a leading national medical billing company serving independent and employed physician groups, hospitals, surgery centers, and behavioral health agencies. AdvantEdge’s over 800 employees leverage the company’s proprietary technology, coding, and workflow tools to ensure that its clients are properly reimbursed for the clinical services they deliver to their patients.

The value of the combined companies provides access to exceptional analytics and RCM technology, expanded market reach and a broader network of experts including coders and bi-lingual call center support personnel. Continued innovation from these two leaders in the practice management and RCM space is another benefit clients can expect.

“Innovation through technology is a critical shared value between our companies, from the billing software developed by AdvantEdge and the Datalytics practice intelligence tools offered through Health Prime,” said David Langsam, CEO and President of AdvantEdge Healthcare Solutions.  “Together, they offer unprecedented efficiency and visibility into actionable information for our clients.   We at AdvantEdge are enthused about joining forces with the Health Prime family and becoming the market leader in revenue cycle management solutions offered to healthcare providers nationwide.”

About Health Prime

Health Prime was created to empower physicians to spend more time with patients and less time attending to paperwork. As a physician owned and managed company, we continually improve the value of our services through dedication to the physicians we serve, leadership and teamwork among our staff and our clients. Health Prime provides a full line of practice management and optimization solutions and services for physicians and hospital owned physician groups throughout the US.

About AdvantEdge

AdvantEdge is recognized as one of the top ten U.S. medical billing companies providing billing, certified coding, and practice management services to healthcare providers nationwide. Our services substantially improve decision making, maximize financial performance, streamline operations, and eliminate compliance risks for our healthcare clients. 

Brentwood Capital Advisors LLC and Falcon Capital Partners served as financial advisors to AdvantEdge.


Download a PDF of this Press Release.

By Darren Whittemore, DO, Dermatopathology at PathologyWatch

If there’s one thing that is constant in healthcare today, it’s change. In our post-pandemic healthcare environment, remote care is essential, and pathology billing and management rely on digital tools for better accessibility and efficiency. But how do EMRs help pathology billing and management?

More than 89 percent of all hospitals have adopted the use of an EMR system or the more overarching electronic health record (EHR) system, which aggregates multiple EMRs to create a more comprehensive collection of patient care. But what do they do exactly? EMRs have many benefits for patients, pathology practices, and medical billing services to ensure departments work together and operate efficiently, even if they are remote. Here are a few of the more common benefits.

How an EMR helps Pathology Practice Management

Experts estimate that most healthcare providers spend around 14.4 hours each week finalizing prior authorizations alone. That doesn’t take into account the delays created by relying on outdated information or data input errors by your office staff. And at what cost? This is valuable time taken away from your patients. 

The incorporation of an EMR system can provide a reduced margin of error in overall patient care due to incomplete or missing records. In fact, as many as 75 percent of providers credit improved patient care to an EHR system, with 88 percent reporting clinical benefits for their practice. EMRs also minimize the need for on-site storage of physical patient records. Because records are stored virtually, not only are they more easily accessible, offices also no longer need to store a backlog in filing cabinets or boxes, which can cost more than $2,000 a year to maintain.

EMRs can create a singular system for charting, including physician notes, pathologist findings, whole-slide images, also known as interoperability, which allows for different systems to share the same patient information between them. While this may not be the case in regards to hospital-based pathology practices—as they are more likely to use the same EMR system as other practices in the hospital—interfacing EMR systems from other practices can require additional technical support in order to achieve interoperability. The benefits of doing so include clearer communication between practices and more accurate diagnostics, resulting in an overall improvement in patient care.

How an EMR helps Pathology Billing

Did you know that insurance claim denials increased by 23 percent in 2020? With governmental changes in healthcare delivery, prior authorizations for medications, coding, and a shift in payer/provider billing models, the administrative burden to sort through these changes to submit valid claims falls on the provider.

A more effective and efficient billing system relies on sharing and processing information quickly. It’s what motivated payers to push for digitizing patient data in the first place, and it has transformed patient care into a coordinated and easily shareable system–on the condition that healthcare providers have the most current billing information. 

According to InstaMed’s Tenth Annual Trends in Healthcare Payments Report, many providers are struggling to keep up with increases in patient collections, with 87 percent of them still leveraging paper and manual processes. Like any other medical service, pathology has its own unique set of requirements when it comes to billing. Those requirements can become even more complex for hospital-based pathology services, as regulations and payer requirements are not only frequently being updated, but so are hospital compliance and other rules.

Among regulations that have recently been updated are the latest changes made to CPT codes. Because coding is a vital element of billing, it’s important that these updates are understood and implemented to provide an accurate assessment of the medical services provided. Once updated, EMRs can then be securely shared with insurance companies and billing services—like AdvantEdge—thereby reducing errors, mitigating paperwork, and eliminating redundancies.

While technology in the healthcare industry is constantly evolving, EMRs are becoming the new gold standard for patient records. Their applications extend beyond improved patient care and accessibility into enhanced practice management and billing solutions for pathology practices. Contact AdvantEdge today to learn more about customized billing, coding, and practice management solutions.

On September 30th, HHS released a second interim final rule (IFR) implementing the No Surprises Act. The rule specifies the independent dispute resolution (IDR) process to be used for “surprise” (i.e. Out-of-Network) reimbursement disputes. This rule applies where state laws don’t exist or lack surprises act

But the No Surprises Act rule immediately generated universal, harsh reaction from physicians and hospitals. 

  • The rule “ignores congressional intent and flies in the face of the Biden administration’s stated concerns about consolidation in the healthcare marketplace,” said Gerald Harmon, M.D., president of the American Medical Association.
  • The American College of Emergency Physicians (ACEP) said, “Emergency physicians are profoundly disappointed that the Administration’s interim final rule (IFR) is almost entirely inconsistent with Congressional intent to create a fair and unbiased process to resolve billing disputes.”

The reaction is because specific directions are given to arbiters to pick an amount closest to the “qualified payment amount” (QPA), essentially the in-network rate. 

  • The rule “essentially puts a thumb on the scale benefiting insurers against providers and will over time reduce patient access,” according to the Federation of American Hospitals.
  •  The American College of Radiology® (ACR®) “is disappointed that the regulations violate the intent of the No Surprises Act by making the Qualified Payment Amount (QPA) the primary determinant of physician payment rates in the independent dispute resolution process.”

Of course, insurance companies see it differently, praising the No Surprises Act rule for creating an “independent resolution process that focuses on affordability,” per Justine Handelman, senior vice president of the office of policy and representation for the Blue Cross Blue Shield Association, which represents 35 Blue Cross plans.

Physician organizations have joined together to oppose the No Surprises Act rule. 

  • The American College of Radiology, the American Society of Anesthesiologists, the American Association of Neurological Surgeons and the American Association of Orthopedic Surgeons have joined in opposition.
    • “Today’s rule does not follow the congressional intent in implementing the law,” Beverly Philip, MD, a Harvard Medical School professor and president of the anesthesiology society, said in a joint statement from the four groups, issued Oct. 1. “The impact will be more record profits for insurers, who are the real winners of this rule, not patients or the physicians who have put their lives on the line throughout this pandemic.”
  • The Radiology Business Management Association, Emergency Department Practice Management Association and Healthcare Business Management Association expressed severe concerns in their own joint announcement.

While lobbying and letter writing will continue, most observers think the September 30 No Surprises Act rule is likely to go into effect on January 1. As a result, physicians who are out of network will now need to prepare a compelling case about why their situation is unique to justify a higher rate than the QPA.

A glimmer of hope was seen recently as Reps. Tom Suozzi, D-N.Y., and Brad Wenstrup, R-Ohio, were circulating a letter addressed to Health and Human Services and other agency heads, asking for their intervention. The two are asking other members of Congress to join them in fighting to fix the interim final rule.

The ACR has pointed out the longer term risks if this rule goes forward, “If the regulations are not changed, the result may be a downward trend of in-network payment rates and/or physicians being dropped from insurer networks.”


No Surprises Act Background

The No Surprises Act specifies factors that can and cannot be considered by the independent arbiter. Specifically, the auditor can consider 

  • The Qualifying Payment Amount (QPA), (which was defined in the first Interim Final Rule as the median in-network rate),
  • Rates for that service in the same geographic area, 
  • The provider’s training and experience, 
  • Each party’s market share, 
  • The complexity of the patient’s case,
  • Other factors unique to the facility such as teaching hospital status and patient case mix.
  • Any bad faith efforts by either party during negotiations for participation in the health plan’s network.  

Arbiters cannot consider 

  • The “usual and customary” rate (typically higher than what insurers pay) 
  • Government payer (Medicare or Medicaid) rates, (typically lower than what commercial insurers pay).


Other implementation details for the No Surprises Act were spelled out in the first Interim Final Rule issued in July. See “5 Things to Know About the No Surprises Act” for more details.


Wall Street Journal, September 30. Medical Cost Disputes to Be Settled by Arbitrator




5 Coding Compliance Questions for Medical Billing Companies

Do you want to collect every dollar owed to your practice or facility? Coding compliance and education both play a critical role. Read our 5 questions to see if your current coding solution is effective. When it comes to medical coding, what you don’t know can hurt your bottom line! Read More

Healthcare Roundup

Medicare | 2 min read

Your Bottom Line at Risk: 10% Cut to 2022 Physician Reimbursement

Without intervention from Congress, all physicians will see an across the board 9.75% cut to 2022 Medicare rates vs. 2021. Plus RVU changes and more. Read More

Radiology | 2 min read

2022 Radiology Billing Changes

There are many forces pulling and pushing on 2022 radiology reimbursement and it’s hard to keep track. Here are the ones we know about today. Read More

PRF | 2 min read

Provider Relief Fund: Reporting Overdue + New Funding Announced

The due date for PRF Period 1 funds to be reported has just been extended. Review key dates for upcoming Periods, and learn more about the additional $25.5B that just opened up “to offset revenue loss and higher expenses due to the pandemic.” Read More

Telehealth | 1 min read

The Future May Not be So Bright for Telehealth

The pandemic caused telehealth services to skyrocket, but as we start to come out of it are these services here to stay? Read our roundup of what the industry is saying. Read More

Lessons Learned: COVID’s Impact on Your Medical Billing

Have you thought about the need to consider the “lessons learned” from COVID? Download our NEW business brief to understand key elements your practice should consider as we shift (hopefully!) to a post-COVID world.


Practice Review Kit




As everyone knows, COVID drove a spike in telehealth usage and put the future of telehealth in a brief spotlight. Video consultations and other virtual care services made medical attention more accessible and convenient. But telehealth usage has now declined. So what is the future of telehealth now?

Telehealth Benefits

Telehealth comes with numerous benefits for both providers and patients:

  • Expanded access to care
  • Reduced patient costs
  • Increased practice efficiency in workflow
  • In some cases, more patient engagement with remote monitoring

In particular, primary care and behavioral health practices found a good match with telehealth. They were quick to adapt their operations to meet the needs of patients during the pandemic with virtual care and, in some cases, remote monitoring. 

Telehealth Usage Growth (During Pandemic + Use Continuing After)

  • CDC studies found telehealth visits represented over 35% of all visits in June of 2020 and that “Telehealth visits declined as the number of new COVID-19 cases decreased but plateaued as the number of cases increased.”
  • Meg Barron, vice president of digital innovation at the American Medical Association (AMA) shared that the percentage of primary care physicians offering telehealth services doubled between 2016 and 2019 – from 14% to 28%. Although the use of telehealth services has dropped off post-pandemic, more practices and patients plan to continue using and expanding virtual services going forward. 
  • A report from McKinsey says that telehealth usage is now 38 times higher than before the pandemic.
  • Hospitals and physicians are carefully monitoring patient expectations for telehealth. In a hospital study by the Center for Connected Medicine, “ninety-two percent of participants said their organizations are measuring and analyzing use of telehealth by patients”.  
  • The American Academy of Family Physicians (AAFP) has cited changes made as a result of the pandemic that they believe should remain after the pandemic is officially declared “over.”
    • HIPAA flexibility
    • Medicare and Medicaid policy changes
    • Licensure requirements
    • Prescribing of controlled substances

Telehealth Usage Decline/ Leveling Off

  • A new survey from KLAS Research and the Center for Connected Medicine indicates a leveling off of telehealth patient visits at 20% or less. 
  • A recent study in Telemedicine and e-Health indicates that even Gen Z patients believe the effectiveness of telehealth is limited to issues like mental health, colds, flus, etc. Also that almost 50% didn’t feel that virtual consultations were as effective as in-person visits. 

The Future of Telehealth Now?

The push and pull between traditional visits and telehealth is not resolved. Many patients want to have telehealth as an option, especially for primary care and behavioral health. They got used to telehealth services during the past year and are now frustrated to find them not available. But two large barriers are limiting the future of telehealth, at least in the short term. 

  • Many states limit the use of telehealth across state lines with licensing restrictions. KHN points out that aside from being a source of state income, “State medical boards don’t want to cede authority, saying their power to license and discipline medical professionals boosts patient safety.” 
  • The McKinsey survey and others indicate that many physicians are not willing to provide telehealth services at a lower rate than in-person services. But CMS and other payers have indicated that they expect lower rates. 

If patient preferences and needs prevail, these factors will eventually be addressed. In the meantime, expect to continue to see a patchwork of telehealth services, depending on your state and payer. 



Provider Relief Fund Reporting

Did your practice receive PRF (Provider Relief Fund) payments over $10,000 from April 10, 2020 to June 30, 2020?

  • If so, the PRF Reporting Portal is open where you must report how the funds were used.
  • Reporting was officially due by September 30 but a 60-day grace period was just added.
  • Recoupment or other enforcement actions will not take place during the 60-day grace period.
  • Unused funds must be returned no later than December 30.
  • Note: this schedule only applies to funds received during “Period 1”, i.e. April 10 to June 30, 2020. 

If your practice received Provider Relief Fund payments after June 30, 2020 the key dates are 

Payment Received Deadline to Use Reporting Period
Period 2 July 1 – Dec 31, 2020 Dec 31, 2021 Jan 1 – Mar 31, 2022
Period 3 Jan 1 – June 30, 2021 June 30, 2022 July 1 – Sep 30, 2022
Period 4 July 1 – Dec 31, 2021 Dec 31, 2022 Jan 1 – Mar 31, 2023


New Provider Relief Funds

On September 29, applications opened for an additional $25.5 billion in PRF funds “to offset revenue loss and higher expenses due to the pandemic.” Applications must be completed before October 26.

  • These funds are targeted at smaller providers and those that have a disproportionate amount of Medicaid and/or Medicare patients.
  • In the press release announcing the new funding, HHS Secretary Xavier Becerra said, “The funding will be distributed with an eye towards equity, to ensure providers who serve our most vulnerable communities will receive the support they need.”


A number of forces are lined up to affect 2022 radiology billing, many of which are cuts. Here is what we know today:

  • Across the board 9.75% cut to the 2022 Medicare Physician Fee Schedule (MPFS) for all physicians
  • Proposed RVU changes for 2022 radiology billing in the 2022 MPFS[1]
    • The ACR says that if Congress does not intervene, the overall reduction for 2022 is approximately 2% for radiology, 9% for interventional radiology,2% for nuclear medicine, and 5% for radiation therapy and radiation oncology.
    • IR and radiation oncology are hit by planned wage increases for clinical labor staff
      • Due to budget neutrality rules, this means cuts in other places. In this case, IR and radiation oncology. Rates for some breast and prostate cancer treatments would be cut by 13%, while some advanced lung cancer treatment rates could drop by 22%.
      • A number of lawmakers have come out in opposition to this change.
      • A coalition has formed to fight the change. It includes the American College of Radiology, Society of Interventional Radiology, American College of Radiation Oncology and the United Specialists for Patient Access.
  • The imaging Appropriate Use Criteria Program penalty phase, that would have affected 2022 radiology billing has been delayed, again. It is now slated for January 2023. However, many experts are arguing for it to be incorporated into Medicare’s broader Quality Payment Program initiatives.
    • In a recent Health Affairs blog, quality experts with Johns Hopkins, Harvard and Weill Cornell advocated for folding the AUC program into similar endeavors.
  • Only minor Quality Payment Program/MIPS changes are expected for 2022 as CMS delays MVP (MIPS Value Pathways) initiatives originally targeted for 2022. MVPs would be incrementally added to the QPP upon availability. CMS has proposed seven MVPs that, if finalized, would become available beginning with the 2023 performance period
    • Rheumatology, stroke care and prevention, heart disease, chronic disease management, lower extremity joint repair (e.g., knee replacement), emergency medicine, and anesthesia.


[1]  In addition to RVU updates, estimates include the effects of redistributive effects of the CMS proposed clinical labor pricing update and phase-in implementation of the previously finalized updates to supply and equipment pricing