RCM Pulse Weekly

CY 2027 Physician Fee Schedule: Proposed 50% Payment Cut on Modifier 25 E/M Visits, 2.5% Efficiency Adjustment, Conversion Factors of $33.17 / $32.84, IPCI Phase-Out With a ±5% PE Stabilizer, G2211 Converts to a 16% Modifier (32% for ACOs) — Comment Deadline September 14 • Prior Auth Enforcement Era: 7-Day / 72-Hour Decision Clocks Live, First Public Payer Denial Scorecards Published March 31, Humana and UHC Gold Card Programs, PA Now 34% of First-Pass Denials • AI Integration Wall: 80% Exploring GenAI, 63% Adopted, 27% at Scale, Only 15% With Realized ROI; Ambient AI Returns 60–90 Minutes/Day and 3.5–6% wRVU Lift • FY 2027 ICD-10-CM: 40-Day Countdown, 190 New Codes Across 33 Clinical Topics, Z86.17, Z68.18/19, E89.830 — Plus the First Maternity CPT Overhaul in 30 Years (59080–59083) • Revenue Velocity: 11.8% Denial Rate, $57 Per Rework, Scrubbing Moves First-Pass Yield 78–82% → 92–95% • KLAS 2026 RCM Suites: Waystar Overall “A”; PitchBook Warns Agentic AI Is Gutting Take Rates After $42.9B in PE Deals • Compliance: Price Transparency Enforcement Live April 1, July 4 FHIR Deadline for CMS Aligned Networks, WISeR Covers 17 Services in 6 States • Independent Practice Watch: 120,900 Independents Left, 82% Employed, MGMA Overhead +29.3% in Five Years • Specialty: Orthopedics −7%, Primary Care G2211 Win, Cardiology ~+1%, Radiology +2–3%, Oncology 340B and Skin Substitutes at $127.28/cm²

FY 2027 IPPS/LTCH Final Rule (CMS-1849-F), Issued August 4: +2.3% Operating Update From a 3.2% Market Basket Less 0.9 Points of Productivity, +$2.1B to Hospitals, +$779M in New Technology Add-On Payments, Three IQR Measures Added and Three Removed, TEAM Expanded to More Spinal Fusion Episodes — Effective October 1 • Two Comment Clocks: OPPS/ASC CMS-1850-P Closes August 31 (340B Moves From ASP+6% to ASP−33.4%, a ~37% Cut; Site-Neutral Extends to Non-Contrast Imaging in Excepted Off-Campus PBDs; IPO List Phase-Out) and CY 2027 PFS Closes September 14 • Prior Auth: 48 Plans and 257 Million Members Under the AHIP Commitments, a 90-Day Continuity-of-Care Window Most Practices Are Not Using, UHC Gold Card Cut PA Volume 30%, and an 80% Real-Time E-PA Mandate Arriving in 2027; WISeR Survived a 46–50 Senate Vote July 16 and Runs to 2031 Across 17 Services, 6 States, 6.4M Beneficiaries • Ambient AI’s Receipts: 15,791 Hours Saved at The Permanente Medical Group, −35% After-Hours Charting and $13,049 Per Clinician at St. Luke’s — Against a 40.4/100 Completeness Score for Ambient-Audio-Only Notes; 63% Adopted, 27% at Scale, 15% With ROI, and IT Infrastructure Is the #1 Barrier at 51% • Coding: 48 Days to FY 2027 ICD-10-CM (238 New, 4 Revised, 21 Deleted; 33 New Codes in O31.4 Alone; D69.1 Splits to D69.11/D69.19; C78./C79. Metastatic Expansion), 58 New Category III CPT Codes, the ABA Rewrite — and G2025 Expires for RHCs and FQHCs in 139 Days • Revenue Velocity: Patient Collections Jump 24% → 31% in One Year as 91.5% Take a Payment Method at the Estimate, While Self-Pay-After-Insurance Falls 5.2% to 29% and POS Sits at 24.4% • Technology: Black Book Rates 420 Vendors Across 49 Categories; XiFin Joins Notable’s Series B August 10; Innovaccer Buys CaduceusHealth (4,000 Practices, $5B in Charges); PitchBook Warns Agentic AI Is Gutting Take Rates • Compliance: Federal IDR Fee Drops $115 → $15 (87%) on 6.34M Disputes, TEFCA Crosses 1 Billion Records, GuardDog Telehealth Permanently Enjoined, Medicaid Work Requirements Start in 140 Days • Independent Practice Watch: 82.0% of Physicians Employed, 253,000 Since 2018, 48,100 in Two Years — but Site-Neutral and 340B Repricing Cut Against the Hospital Arbitrage • Specialty: Orthopedics −7% With Knee and Hip Work RVUs Down 20.8%, Oncology Facing ASP−33.4%, Primary Care Banking APCM at $16.30/$53.50/$116.00 a Month, Behavioral Health Exempt From the 2.5% Efficiency Adjustment

Software as a Medical Service: CMS-1850-P Proposes Status Indicator “O1,” 36 HCPCS Codes Designated SaMS With 21 Moving to New Technology APCs, OPPS/ASC +2.4% — Comment Deadline August 31 • CY 2027 PFS: Conversion Factors $33.1693 / $32.8409, ±5% Practice Expense Stabilizer, Traditional MIPS Sunsets in 2029, New QPP Incentive for Responsible AI Use — Comment Deadline September 14 • Prior Auth on Two Tracks: CMS-0062-P Extends the 7-Day / 72-Hour Clock to Drugs and Proposes FHIR Under HIPAA Administrative Simplification; UHC Gold Card Cut PA Volume 30%, Cigna Has Pulled 1,100+ Codes; MA Denial Rates of 12.8% UHC / 11.9% Aetna / 5.8% Humana • AI in RCM: 63% Adopted, 27% at Scale, 15% With Realized ROI — Only 14% Point AI at Denials Though 69% of Those Who Do See Fewer; CMS Orders Corrective Action on Its Own WISeR AI Contractor • Coding Countdown: 55 Days to FY 2027 ICD-10-CM — 238 New Codes, 4 Revised, 21 Deleted, C78./C79. Expansion, D69.11 and D69.19 — Plus the CPT 2027 Maternity Teardown and 58 New Category III Codes • Revenue Velocity: 11.8% Initial Denial Rate, 15.7% in Medicare Advantage, $57.23 Per Rework; Kodiak Reports $48B Lost Across 2,300 Hospitals; POS Collections Rise to 24.82% While Patient Yield Falls to 30.07% • Technology: Waystar Takes the KLAS 2026 RCM Suites “A,” Ensemble Beats R1 by 42.9 Points, Healthcare RPA Grows to $7.14B by 2033 With a 6–9 Month Payback • Compliance: HIPAA Security Rule Slips to July 2027 With a One-Year BAA Clock, Price Transparency MRF RFI Open to August 31, TEFCA Crosses 500 Million Records • Independent Practice Watch: Only 24% See Their Revenue Leakage, 85,000 Practices Acquired Since 2018, 48,100 Physicians Left Independence Since 2024 — Yet Just 2% Want Out • Specialty: Orthopedics −7%, Cardiology ~+1%, Radiation Oncology Delivery Codes +23%, CTA Chest 71275 +149%, GI Loses 91120 / 91122, Primary Care Gains a 16% G2211 Modifier

CY 2027 OPPS/ASC Proposed Rule: 2.4% Rate Bump, 340B Reimbursement Cut to ASP−33.4%, Imaging Site-Neutral Expansion, Comment Deadline August 31 • MA Prior Auth Denial Surge: 31% YoY Increase, AI Payer Systems Driving Upfront Rejections, 80.7% Overturn Rate When Appealed, Only 11.5% Appealed • Abridge $316M Series E + Availity PA Integration; Microsoft Nuance Tops KLAS CDI; 63% of Providers Have AI But Only 15% Fully Integrated • FY 2027 ICD-10-CM: 62-Day Countdown, 190+ New Codes, O31.4 Vanishing Twin, Z68.18/19 BMI Underweight, J34.83 Odontogenic Sinusitis • WISeR Prepayment Review in 6 States; Automation Boosts Net Collections 15%; KPI Benchmarks for H2 2026 • Ambient AI Duopoly: Abridge vs Nuance; MA Plan Exit Credentialing Crisis in 109+ Counties • Independent Practice Watch: 85,000 Practices Acquired Since 2018, 29,600 MDs to Hospital Employment in 2025, 340B Impact on Consolidation • Specialty: Cardiology 340B/HOPD Imaging, Oncology ASP−33.4% Threat, Ortho CPT Tightening, Mental Health Permanent Telehealth Win

CY 2027 PFS Comment Window Open: ASM Rural Adjustment, Permanent Behavioral Telehealth, MSSP Benchmarking Reform • Payer PA Mid-Year Scorecard: Aetna 88% Standardized, UHC July Policy Drops, 7-Day Decision Clock in Effect • Candid Health $120M Series D (July 22); AI in RCM Market $21.49B Growing 27% CAGR; CodaMetrix 70% Denial Reduction • FY 2027 ICD-10-CM 10 Weeks Out: Oncology Radiation Level 1/2/3 Codes, IMRT Deleted, GI MVP 11 Quality Measures • Revenue Velocity KPIs: 97% Clean Claim Rate Top Target, 3-Gap Automation Audit • KLAS 2026 RCM Suites Report: Waystar ‘A’ Rating, Partnership Quality Predicts ROI • CMS July 2026 Enforcement Dataset Live; MRF Actual Payment Data Required • Independent Practice Watch: $210.4B Market, AI Now Entry Fee Not Differentiator • Specialty: Cardiology ASM Rural Adjustment, Orthopedics 7-Day PA Clock, Mental Health NQTL Enforcement

CY 2027 PFS Proposed Rule: −1.68% Conversion Factor, Same-Day E/M + Global Bundling at 50%, Comment Deadline September 14 • Medicare Advantage Denial Emergency: 17% vs. 8% Traditional Medicare, 2.9M Patients Disenrolled, Authorization-Gap Crisis • Agentic AI Race: $19.71B Market by 2034, What’s Production-Ready Now vs. 2027–2028 • HCPCS Q3 2026 Updates Live, CPT Assistant 2027 L&D Preview, FY 2027 ICD-10 11 Weeks Away • HFMA/Guidehouse: 20% of Practices Exceeding 5% Denial Rate • Price Transparency Phase Two: 500+ Hospital Warning Letters, EDI 835 Required • CMS Drug PA Interoperability Rule: 24-Hour Medicaid Turnarounds • Independent Practice Watch: 18% Physicians Independent, Need 6%+ Growth to Hold Margin • Specialty: APCM G-Codes Live, Oncology 38% Ibrutinib Cut, Radiology MRI Codes 76014–76019

CY 2027 OPPS/ASC Proposed Rule: 340B Restructuring, Site-Neutral Expansion, Botulinum Toxin PA Expansion; Comments Due August 31 • AHIP Pledge Year One: 11% of PA Requirements Eliminated, 6.5M Fewer Requests; Aetna 88% Standardized • The Hybrid Model Wins: AI-Assisted Human Billing, 451% ROI, Clinical Denials Still Need Humans • Mid-Year Coding Audit: Z21 Sequencing, E11.A Remission, BMI-Only Claims Before FY 2027 • Denial Labor Tax: 51–75 Hours/Week, 41% Writing Off $5M+ • RCM M&A Wave: Experity Buys Exdion, Waystar/Iodine $1.25B • HIPAA Security Rule Slips to 2027 but OCR Enforcement Live Now • MGMA 2026 Squeeze: 84% Higher Costs, 47% Higher Revenue • Specialty: ASM Roster Errors, CCM +10%, WISeR States, Oncology 340B

OBBBA Work Requirements Live July 1 in Montana & Arkansas; 6-Month Countdown to Nationwide Rollout • NewYork-Presbyterian Exits UHC MA Network July 1; Continuity-of-Care Window Through September 28 • Task-Level vs. System-Level AI: 63% Adoption, Only 15% Full Integration • NCCI Q3-2026 AOC Edits Live; AX Modifier Eliminated for ESRD TDAPA; HCPCS Quarterly Update July 6 • 2026 RCM Benchmarks: Days in AR Under 30, Clean Claims 98.7%, Denial Rate Below 5% • Black Book AI-RCM Rankings: Waystar, Experian Health, AKASA, R1; $18B Denial Overturning Cost • Q4 2026 Compliance: CMS-0062-P Final Rule Imminent; ICD-10 FY 2027 October 1 • Specialty: RPM Codes 99445/99470, Orthopedics −2.5%, Oncology Navigation Codes, Neurology AI-EEG CPT

OBBBA Coverage Unraveling: 10–17M Medicaid Patients at Risk, $24B Uncompensated Care Projected • Cigna 70% PA Standardization by Year-End; Full Payer PA Scorecard • UiPath BOAT Full-Stack RCM Framework; 86% of Practices Leave Revenue on the Table • EEG Code Family Revisions & 6 New MRI-Safety CPT Codes 76014–76019 • Net Collection Rate Gap: 95%+ Target vs. 83–89% National Median • Fathom in Epic App Orchard; Nym Health Clinical Benchmark; 120+ AI Tools Commoditization Risk • OBBBA Provider Tax Freeze; Audio-Only Telehealth Restrictions; H2 2026 Compliance Calendar • Independent Practice: OBBBA Double Exposure — Medicaid & ACA Marketplace Panels at Risk

MA Network Crisis: 21 Health Systems Exit, 2.9M Enrollees Displaced • UHC 30% PA Reduction Rolling Out: Echocardiograms & Outpatient Surgery PA-Free for 50M Members • Black Book’s 9 Under-the-Radar AI Innovations: Governance Now the Differentiator • FY 2027 ICD-10: 238 New Codes Oct 1; GI Colonoscopy Denial Surge • Smarter Technologies $800M Launch: SmarterDx + Thoughtful.AI + Access Healthcare • Cybersecurity: TriZetto 2.5B-Transaction Breach; TiC Rule Proposed Update • Independent Practice: AI Governance Gap at 77%; M&A Accelerating

URGENT: CMS-0062-P Drug PA Rule Comment Deadline June 15 • Massachusetts Eliminates PA for Primary Care, Cancer Scans & Chronic Disease Meds • HFMA 2026: McKinsey Projects 30–60% Cost-to-Collect Reduction With AI; FinThrive Fusion & UiPath Agentic AI Debuts • Radiation Oncology Overhaul: Level 1/2/3 Replace Simple/Complex; IMRT 77385–77386 Deleted • Cardiology LAA Occlusion wRVU Cut 26.8%; PCI Family Revised • 2026 AR Benchmarks: Days in AR 30–40, Clean Claims ≥95%, AR Aging Ratios • Agentic AI RCM: $1.83B Market Growing to $19.71B by 2034 at 34.61% CAGR • Independent Practice: 30% Revenue Decline; Medicaid Risk Modeling for 2027 • Specialty: Primary Care PIN Codes, Cardiology LAAO Cuts, Oncology Coding Overhaul

CY 2027 MA & Part D Rule Effective June 1: Star Ratings Overhaul, PA Continuity & Part D Redesign • Medicaid Community Engagement IFR: 80 hrs/month Work Requirement, Jan 2027 State Deadline • athenahealth 80+ AI Features: 30% Coding Denial Recovery, 16% Fewer Insurance Denials, PA Voice AI <1hr • CoCM Billing Code Alert: 99492–99494 Retired, G0568–G0570 Required Now • Denial Rates Hit 20%; 60% Never Appealed; Prevention-First KPI Playbook • Black Book Research: 74% Shift to Denial Prevention, Revenue Cycle Now Board-Level Infrastructure • Price Transparency Enforcement Active; Drug PA Comment Deadline ~June 13 • Independent Practice: 15% AI-Integrated; Medicaid Panel Risk Modeling for 2027 • Specialty Spotlight: Cardiology UHC–NYP, Orthopedics −2.5% Cut, Mental Health Telehealth Expansion

CMS-2449-P: $775B Medicaid Supplemental Payment Cap Proposed • UHC Eliminates PA for 30% of Services: 50M Members, Echocardiograms & Outpatient Surgery First • Innovaccer Acquires CaduceusHealth $66M: First Autonomous RCM Platform for 4,000 Providers • CPT 2026 AI-Assisted Diagnostic Codes: Lung Nodule, Stroke AI, Mammogram Comparison Now Billable • 97% Clean Claims Benchmark: 0.3–0.5 AR Days per Point Below • CMS Price Transparency Enforcement Active: Median Allowed Amounts, Type 2 NPI, CEO Attestation Required • Independent Practice: 60% Denied Claims Never Resubmitted — $30K–$80K Recovery per Physician • Specialty Spotlight: Mental Health PA-Exempt, Radiology AI CPT Codes, Cardiology ASM Prep

ASM Mandatory for 8,600 Cardiologists & Back-Pain Specialists Starting Jan 2027 • Aetna 95%+ PAs in 24 hrs; Cigna Migrates to CoverMyMeds • RCM AI Market: $21B → $71B by 2031; Fathom Enters Epic App Orchard • ICD-10-CM FY2026: 487 New Codes — E11.A Diabetes Remission & HIV Z21 Now Audit Risk • Clean Claims Rate: 95% Floor, Zero-Day Denial as Gold Standard • UHC Mandates Full Radiology Interpretation Reports; Waystar IPO • $5.7B Healthcare FCA Recoveries FY2025 — HIPAA Tracking Tech Enforcement • 97% of Practices Outsource RCM; Only 15% AI-Integrated • Specialty Spotlight: Primary Care APM Premium, Cardiology ASM, Oncology CMS-0062-P Deadline

CMS Medicaid Managed Care Final Rule: Network Adequacy & PA Data Reporting Mandated • Gold Carding Expands: Cigna 15K+ Providers, Humana 3-Tier PA Reform • Agentic AI: AKASA 1-Agent = 14 Staff, Thoughtful AI 4.2% Denial Rate • HCC Risk Adjustment Gap: $2.8B Missed by Independent Practices • First-Pass Resolution Rate: The Hidden KPI • Payer AI Denial Engines vs. Counter-AI Platforms • OIG 2026 Work Plan: Telehealth, E/M & Medical Necessity Active Audits • MGMA 2026 Compensation: Independents Earn 12% Less • HPSA Bonus: 10% Medicare Bonus, 2,400 New Designations

CMS-0062-P Drug PA: 24-Hour / 72-Hour Decision Windows, Mandatory ePA by Oct 2027 • UHC Cuts 30% More PAs; Payer Pushback Drives 78% of Payment Delays • Oliver Wyman: 63% of Health Systems Run AI in RCM; Only 8% Expect “Very High” ROI • April 2026 ICD-10-CM Update: Opioid, Autoimmune & Post-COVID Codes • The 25-Day Club: Top Performers Cut Days in A/R Below 25 • CodaMetrix Cuts Coding Denials 59%; 2026 Best in KLAS RCM Winners • Hospital Price Transparency Enforcement Begins April 1 • Only 42.2% of Physicians Still in Private Practice

H.R. 1 Signed: Medicaid Provider Tax Freeze, Payment Caps & One-Year Medicare Lifeline • PA Reform Scoreboard: Aetna 88%, Cigna 70% • Waystar $1.25B Iodine Acquisition • CPT 2026: First AI-Augmented Billing Codes • Top Practices Collecting in Under 24 Days

CMS CY 2027 MA Final Rule Takes Effect; Price Transparency Enforcement Active as of April 1 • AHIP Spring PA Progress Report Due: Reform Pledges Meet the Reality of Still-Rising Denials • Agentic AI Arrives: Waystar Claims $15.5B in Prevented Denials; Only 15% of Providers Fully Integrated • ICD-10-CM Note Changes Now Live in 14 Chapters; Cardiology PCI Overhaul and New AI Diagnostic CT Codes • The 25-Day A/R Target: How Top Performers Are Widening the Gap in 2026

CMS Drops Drug PA Interoperability Rule; H.R. 1 Puts Medicaid Eligibility on a New Clock • The MA Denial Crisis Deepens: 56% Jump in PA Denials, 80.7% Overturned on Appeal • Ambient AI Delivers Measurable Revenue Lift: 11% wRVU Gain, 14% More HCCs Documented • New CPT Codes in Play: AI-Enhanced Cardiac CT Billable, RPM Splits, GI and Neurology Updates • The MA Denial Tax: $47 Per Claim — How Rework Costs Are Eroding Revenue Velocity

Hospital Price Transparency Enforcement Is Live — What Every Practice Must Know Now • PA Reform Wave Continues: UHC, Cigna, Aetna Deliver on January Commitments • Agentic AI Is No Longer a Pilot — Autonomous Revenue Cycle Operations Go Mainstream • April 1 ICD-10-CM Update: Instructional Note Changes That Will Shift Your Coding • Closing the Gap: 2026 RCM Benchmarks and the Revenue Velocity Playbook

CMS Drops CY2027 MA Final Rule and April 1 ICD-10 Notes Reshape Coding — A Week of Back-to-Back Regulatory Moves • PA Transparency Era Begins: March 31 Deadline Forces Payers to Publish Denial Data for the First Time • AI Is Becoming the Revenue Cycle Operating System — Agentic Workflows Now Handle the Full Denial Loop • April 1 ICD-10 Update: No New Codes, But Excludes1-to-Excludes2 Conversions Could Unlock Missed Revenue • Days in A/R, Denial Rates, and Clean Claims: Where the Industry Stands Heading Into Q2

CMS Finalizes Electronic Claims Attachments Rule — $782M in Annual Savings, Fax Machines on Notice • March 31 PA Metrics Deadline Looms as Payers Publicly Report Denial Data for the First Time • HIMSS26 Unleashes Agentic AI Arms Race — Waystar, Epic, and FinThrive Ship Autonomous RCM Agents • 36 New HCPCS Codes Drop April 1 — Plus Critical ICD-10 Excludes 1 Enforcement at UHC • Days in A/R Benchmarks Tighten as Denial Rates Hit 11.8% and $262B in Claims Go Unpaid

Regulatory/Payment Updates — CMS PFS Correction Rule and Part D Out-of-Pocket Cap Take Effect • Prior Authorization / Payer Relations — AHIP Voluntary PA Reforms Now Live; Payers Trim MA Networks • AI & Automation Deep Dive — Agentic AI Crosses Into Autonomous Revenue Cycle Operations • Coding Updates — CPT 2026 Coronary Revascularization Overhaul and Radiation Oncology Code Restructure • Revenue Velocity / KPIs — Zero-Day Denials and the Race to Sub-30 Days in A/R

Medicare Advantage Plans Cut Benefits and Geographic Coverage for 2026 • Prior Authorization Real-Time Decision Mandate: 80% by 2027 • Healthcare Eligibility Verification Automation: 60-90% of Verifications Now Autonomous • FY 2026 ICD-10-CM Guidelines: Major HIV Coding Revisions Take Effect • RPA Adoption in Revenue Cycle Management Reaches 50-75% of U.S. Hospitals

CMS Physician Fee Schedule 2026: 3.26% Rate Increase and Key Payment Updates • Prior Authorization Reform Takes Effect: Industry-Led 72-Hour Response Commitment • AI-Powered RCM Reaches Critical Mass: 63% of Providers Already Using AI • CPT 2026 Recognizes AI-Augmented Services for the First Time • Denial Rates Surge to 15%: AI Denial Prevention Becomes Standard Practice

Medicare Advantage Market Disruption: 10% of Enrollees Forced to Switch Plans • RADV Audits Accelerate: Payment Year 2020 Reviews Now Underway • The Autonomous Coding Revolution: AI Medical Coding Market Update • ICD-10 and CPT 2026: Critical Guideline Changes You May Have Missed • Denial Management in 2026: Upstream Prevention Replaces Downstream Recovery

CMS 2026 Payment Updates: What Your Practice Needs to Know • Prior Authorization Reform: 50+ Payers Commit to Major Changes • AI and Automation: The Agentic Revolution in RCM • CPT and ICD-10 Code Updates for 2026 • Revenue Velocity: 7 KPIs Every Practice Should Track