The Question · 44 questions · 6 specialties
The Question: one revenue question a week, answered with the numbers.
Our CEO, Suresh Padmanabhan, posts one researched question each week on LinkedIn for leaders of ABA, physical therapy, mental health, hospital, FQHC and emergency department organizations. Each one is answered here with primary sources, a diagram and a two-minute self-check.
ABA therapy
The questions we put to aba therapy leaders, each answered on a page that shows the numbers. Want us to run yours? See our aba therapy billing services.
If the first reader of your treatment plan is software, do you write for the machine or for the clinician who signs the denial?
84% of health insurers use AI/ML (NAIC, 2025)
Read the answer →Q2When OIG finds a documentation defect in 100 of 100 samples, at what point does it stop being paperwork and become a false claim?
4 OIG state audits, $197.9M improper, every sample flawed
Read the answer →Q3Indiana capped weekly ABA hours and added a 4,000-hour lifetime limit. Who should own that decision: the payer, the BCBA or the family?
Indiana BT202627: 6% cut, 4,000-hour lifetime limit
Read the answer →Q4The 2027 ABA code set is changing. What should you demand in writing from your practice management vendor this quarter?
Revised adaptive behavior codes effective 2027
Read the answer →Q5A state cuts RBT rates by nearly half. Is there any answer other than cutting hours or cutting pay?
2026 Medicaid ABA rate cut wave
Read the answer →Q6Should ABA providers pool their real cost data and take it to payers, or is every clinic still negotiating blind?
State ABA rate moves tracked quarter by quarter
Read the answer →Q7When a state ties ABA billing to accreditation, does it raise quality or just push small clinics out?
Indiana accreditation bulletin BT202646
Read the answer →Q8Guaranteed hours for RBTs through cancellations: can an ABA clinic afford it when payers cut rates?
RBT pay, cancellations and 97153 rates
Read the answer →Q9Your NPPES taxonomy says one thing and the BACB registry says another. Which one is your payer reading?
Optum taxonomy mandate 2026
Read the answer →Q10Texas Medicaid enrollment for ABA is serial: TMHP, then the credentialing CVO, then each MCO. Are you planning for 5 to 7 months?
TPIs retired; PEMS, CVO, then MCO contracts
Read the answer →Q11Medicaid ABA spend grew more than fourfold in four years. What is the honest number behind that growth?
$1.94B in 2021 to $10.1B in 2025 (CMS)
Read the answer →Q12Who funds ABA when a child turns 21 and EPSDT ends, and what should a provider build now?
EPSDT ends at 21; state plans differ
Read the answer →Q13What is the last growth decision you put off because your back office could not give you a straight answer on timing, rates or rules?
TRICARE ABA authorizations run six months under a demonstration authorized through Dec 31, 2028 (TRICARE).
Read the answer →Q14From the first call to the final statement, how many handoffs does one ABA client go through, and can you name the owner of each?
Nine links from credentialing to client statements, and revenue leaks at each handoff.
Read the answer →Physical therapy
The questions we put to physical therapy leaders, each answered on a page that shows the numbers. Want us to run yours? See our physical therapy billing services.
Medicare's own example: 24 min of 97112 plus 23 min of 97110 bills 3 units. Counted code by code, it is 4. Do you bill every payer the Medicare way, or read each contract?
47 timed minutes = 3 units on Medicare's total-time table, 4 units counted per code (CMS Claims Processing Manual, ch. 5, sec. 20.2, Example 1).
Read the answer →Q2Many PT clinics assume commercial payers count timed units per code. At least one major commercial policy uses Medicare's total-minutes table. Is your unit rule set by policy number or by habit?
Anthem commercial reimbursement policy C-07002 (NY), effective Aug 13, 2025, uses the same 8 to 22 minute, 23 to 37 minute table as Medicare.
Read the answer →Q3CMS proposes ending traditional MIPS after 2028. If your PT practice sits near the low-volume line, do you opt in and build the data now, or stay out and pay later?
CY 2027 PFS proposed rule: traditional MIPS sunsets after the 2028 performance period; MVPs only from 2029 (CMS QPP fact sheet, July 2026).
Read the answer →Q4CMS proposes replacing seven PT functional status measures with PROMIS-based outcome measures in 2027. Do you change your intake outcome tool now, or wait for the final rule?
Q217 to Q222 and Q478 proposed for removal, five new patient-reported outcome measures proposed (CMS CY 2027 QPP proposed rule fact sheet).
Read the answer →Q5The proposed 2027 conversion factor for most PT practices drops 1.68% to $32.84. Do you renegotiate commercial rates off Medicare, or cut cost per visit?
Nonqualifying APM conversion factor proposed at $32.8409, down from $33.4009 in 2026 (CY 2027 PFS proposed rule, July 2026).
Read the answer →Q6Above $2,480 a Medicare PT claim needs KX. Above $3,000 it can be picked for targeted review. Do you treat KX as a checkbox or as a sworn statement about the chart?
CY 2026 KX threshold $2,480 for PT and SLP combined; targeted medical review threshold $3,000 (CMS Therapy Services page).
Read the answer →Mental health
The questions we put to mental health leaders, each answered on a page that shows the numbers. Want us to run yours? See our mental health billing services.
Medicare pays 150% for crisis psychotherapy delivered outside the office. Is your crisis team billing the higher code, or leaving it on the table?
G0017/G0018 pay 150% of the non-facility fee schedule amount outside the office, since Jan 1, 2024 (CMS, CAA 2023 sec. 4123).
Read the answer →Q2The 85% federal match for Medicaid mobile crisis closes on March 31, 2027. Does your crisis program survive at the regular match, or does it shrink?
Section 1947 pays an 85% federal match for 12 quarters, in a window that closes Mar 31, 2027 (42 U.S.C. 1396w-6).
Read the answer →Q3Medicaid work requirements start January 1, 2027. Should your BH clinic help patients prove the medically frail exemption, or leave it to the state?
Work rules start Jan 1, 2027; on Oct 29, 2026 a federal court struck CMS's extra impairment test for medical frailty (D. Mass.).
Read the answer →Q4States will look at 12 months of your claims to decide who is exempt from Medicaid work rules. Do your diagnosis codes tell that story?
CMS-2454-IFC tells states to verify frailty from paid, pended and denied claims in the preceding 12 months (91 FR 33348).
Read the answer →Q5The 2024 parity rule is not being enforced. Do you stop pushing payers on NQTLs, or use the parts of the law still in force?
Since May 15, 2025, DOL, HHS and Treasury do not enforce the 2024 MHPAEA rule; the CAA 2021 NQTL analysis duty still applies (DOL).
Read the answer →Q6From 2028, new Medicare telehealth therapy patients need an in-person visit first. Do you onboard now, or wait for Congress to delay it again?
CMS telehealth FAQ (updated Oct 8, 2026): the in-person rule applies after Dec 31, 2027; patients started before then are grandfathered.
Read the answer →Hospitals and health systems
The questions we put to hospitals and health systems leaders, each answered on a page that shows the numbers. Want us to run yours? See our hospitals and health systems billing services.
Medicare Advantage plans must follow the two-midnight benchmark since 2024. When a plan downgrades your inpatient stay, does your team argue screening criteria or cite 42 CFR 412.3?
CMS FAQ memo, Feb 6, 2024: MA plans must follow the 412.3 inpatient criteria, including the two-midnight benchmark.
Read the answer →Q2Only 11.5% of denied Medicare Advantage prior auth requests were appealed in 2024, and 80.7% of appeals were overturned. Is not appealing a staffing decision or a revenue decision?
KFF, Jan 2026, from CMS Part C data: 4.1 million MA prior auth denials in 2024, 11.5% appealed, 80.7% overturned.
Read the answer →Q3Under WISeR, your outpatient facility claim is reviewed, but gold card exemptions go to individual physician NPIs. Who in your hospital is tracking which surgeons have one?
CMS WISeR exemption fact sheet: gold cards are granted per individual NPI, minimum 10 requests, affirmation bar no higher than 90%.
Read the answer →Q4WISeR lets hospitals skip prior authorization and take prepayment review instead. In Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, which would you choose for a cervical fusion?
CMS WISeR FAQ: determinations typically in 3 days; claims with no request go to prepayment review for dates of service from Jan 15, 2026.
Read the answer →Q5From January 1, 2027, some 340B savings arrive as rebates due within 10 days of complete claims data. Who owns that data in your hospital: pharmacy or revenue cycle?
HRSA notice, 91 FR 48883, Aug 3, 2026: revised 340B rebate pilot effective Jan 1, 2027, rebates due within 10 calendar days of a complete claim.
Read the answer →Q6CMS sent price transparency noncompliance letters to 519 hospitals this spring, but fined very few. Is your machine-readable file a compliance task or a revenue risk?
HHS and CMS confirmed 519 hospitals received noncompliance letters between April and early June 2026 (AP, June 9, 2026).
Read the answer →FQHCs
The questions we put to fqhcs leaders, each answered on a page that shows the numbers. Want us to run yours? See our FQHC billing services.
The Health Center Fund expires Dec 31 and the stopgap funding bill ends Dec 11. Do you budget 2027 assuming Congress extends it, or assuming a gap?
Section 330 grants were 10% of $55.4B in health center revenue in 2025 (KFF, Oct 2026, from UDS data).
Read the answer →Q2Section 330 brings in $982 per uninsured patient. Medicaid brings $1,609 per patient. For 2027, is your bigger risk the federal grant cliff or patients losing Medicaid?
2025 revenue per patient: Medicaid $1,609, Section 330 per uninsured patient $982 (KFF analysis of UDS, Oct 2026).
Read the answer →Q3UDS Table 9D moves from cash to accrual for 2026. Should the numbers HRSA sees come from your billing system or from your auditor's books?
HRSA PAL 2026-05 (Sep 8, 2026) shifts Tables 9D and 9E from cash to accrual for reports due Feb 15, 2027.
Read the answer →Q4HRSA now wants sliding fee discounts reported as self-pay adjustments and bad debt on its own line. Does your billing system already keep those two apart, or will someone sort it in a spreadsheet in February?
2026 UDS: sliding fee moves to Line 13 Column D, bad debt to new Line 15 (HRSA PAL 2026-05).
Read the answer →Q5Medicaid work requirements start Jan 1, 2027: 80 hours a month for expansion adults. Who at a health center should own the coverage check: the front desk, enrollment staff or billing?
44 states must apply work requirements from Jan 1, 2027 (KFF tracker, updated Nov 3, 2026).
Read the answer →Q6Medicare pays FQHC telehealth through Dec 31, 2027, but G2025 is gone and every line needs a real code. Do you grow telehealth now, or start pulling it back before 2028?
Health centers ran nearly 19 million telehealth visits in 2025, 13% of all visits (KFF, from UDS).
Read the answer →Emergency departments
The questions we put to emergency departments leaders, each answered on a page that shows the numbers. Want us to run yours? See our emergency departments billing services.
Three states passed downcoding laws in 2026. Will they cut ED level 5 downcodes, or just make insurers write better denial letters?
Indiana and Virginia now require at least 180 days to appeal a downcode and notice with CARC/RARC codes (IC 27-1-52; Va. Code 38.2-3407.15).
Read the answer →Q2Your ED's biggest payers are self-funded employer plans. Is a state downcoding law worth citing in your appeals, or is it a distraction?
Illinois passed its Transparency in Downcoding Act in 2026, but it does not take effect until January 1, 2028 (Illinois House, WBEZ).
Read the answer →Q3Should your ED physicians write observation orders at all, or hand every observation patient to the hospitalist and keep the ED code?
Medicare does not pay an ED visit and initial observation care by the same practitioner on the same date (CMS Claims Processing Manual ch. 12, 30.6.9.1).
Read the answer →Q4Your patient leaves observation 7 hours 50 minutes after the order. Is a 10-minute gap worth a different code family?
Under 8 hours on the same date bills 99221-99223 only; 8 to 24 hours bills 99234-99236 (CMS Claims Processing Manual ch. 12, 30.6.9.1).
Read the answer →Q5A payer downcodes chest pain to level 3 because the final diagnosis was benign. Appeal on the symptoms, or accept it as the cost of a busy ED?
Federal rules bar plans from deciding what is an emergency solely on diagnosis codes; the prudent layperson test uses presenting symptoms (45 CFR 149.110).
Read the answer →Q6Federal IDR has taken in 7.8 million disputes since 2022. For ED groups, is IDR now a revenue line or an overhead line?
7,798,616 IDR disputes were initiated from April 15, 2022 to September 30, 2026, and batched disputes are capped at 50 line items from November 1 (CMS IDR report; CMS operations final rule fact sheet).
Read the answer →Have a question we should ask?
Tell us the revenue problem keeping you up at night. A senior partner replies within one business day, and the best ones become the next question in the series.