Consulting

Medicare clinical laboratory billing entered another round of updates on October 1, 2026. New laboratory codes, revised diagnosis requirements, CLIA-related changes, and updated medical necessity edits are now affecting how certain laboratory claims are coded, validated, and processed. For laboratories and healthcare organizations, the concern is not simply keeping code sets current. Changes must also […]

Hospital price transparency is entering another period of regulatory scrutiny. While hospitals are already responsible for meeting strengthened requirements that took effect in 2026, CMS is considering additional changes that could shape how pricing information is reported and compared in the future. For revenue cycle leaders, the distinction matters. The 2026 requirements are finalized and […]

Two payers can reimburse the same amount for the same type of claim and still create very different financial outcomes for a healthcare organization. Consider two hypothetical payers. Payer A reimburses $1,000, processes the claim in seven days, and requires minimal follow-up. Payer B also reimburses $1,000 but takes 45 days to process the claim […]

AI is taking on more repetitive work across healthcare revenue cycle management. Claim status checks, work queue routing, basic edits, denial categorization, and routine follow-up can increasingly be supported by automation. But that raises a more important question for specialty RCM. If AI handles the easy 80 percent, what becomes more valuable in the other […]

Hospitals can provide a service correctly, document it appropriately, and still lose revenue if that service never becomes an accurate charge. This is why charge capture and Charge Description Master management are central to hospital revenue integrity. Charge capture determines whether procedures, supplies, medications, implants, and other billable services reach the patient account. The CDM […]

Hospital revenue leakage rarely begins with one large failure. More often, it develops when smaller errors move from one revenue cycle function to the next without being corrected. An eligibility mismatch can become a registration problem. A missed authorization can turn into a denial. Incomplete documentation can affect coding. A missing charge can reduce claim […]

Spine surgery can generate significant hospital revenue, but it also creates some of the most difficult claims to get right. A single case may involve multiple spinal levels, decompression, fusion, instrumentation, implants, grafts, imaging, assistant surgeons, and different facility and professional billing requirements. That complexity creates financial exposure. A missing procedure, incorrect code combination, authorization […]

Cash flow in an anesthesia group depends on more than case volume. Revenue must move through a billing model where reimbursement is influenced by anesthesia time, base units, payer conversion factors, modifiers, medical direction requirements, documentation, and contract terms. That makes anesthesia revenue cycle management different from many other specialties. A completed case does not […]

Cardiovascular surgery billing brings together some of the most complex clinical, coding, and reimbursement requirements in a hospital. A single case may involve the operating room, anesthesia, perfusion, pharmacy, imaging, intensive care, implants, blood products, and several physicians. Each part of the episode creates information that must reach the final claim accurately. The financial risk […]

A claim is denied, not because the service was unnecessary, the coding was wrong, or prior authorization was missing, but because a patient never returned a form. That’s the frustrating reality behind the PR‑227 denial code. In many practices, these denials pile up quietly in the A/R queue, delaying payment, increasing work for billing staff, […]