Just Published · October 2026 Upgrade
20 new pieces. The October upgrade.
October brings the new emergency department billing page with a 184-rule, 50-state ER payer matrix, the October refresh of the ABA, behavioral health, therapy and FQHC payer matrices (98 new verified changes), the RCM terms and acronyms A to Z, and 20 new insights, guides, white papers and case studies. Every fact is linked to its primary source. No download form, no SDR follow-up.
5New case studies
5New white papers
5Newsletter issues
1Annual recap
38K+Words of new content
Published 27 October 2026: 100 new pieces and six payer matrices.
Case study · ABAABA compliance sweep: 370K lines, 0 over-billed, and a $2.82M scare that shrank to $72KEvery line of a multi-state ABA book tested: 100% units-vs-time, 100% authorization linkage, and a modifier exposure that shrank once credentials were matched.Case study · ABAABA first-pass yield: the 65.8% hiding inside a 92.5% reportHow a naive first-pass count of 92.5% became a true 65.8%, and the remit-coverage test that found $5.05M of claims nobody had answered.Case study · CorePulseOne-call VOB: 22 service types, and the gaps in the 271Second calls per VOB 23% to 0, 98.8% batch success on 658 rows, PT benefits on only 11% of general 271s, and 10,574 fabricated $0 rows zeroed.Case study · CredProCredentialing hold AR: $1.03M to about $170K in four monthsOn a 91-payer health center book the credentialing hold queue fell from $1.03M to about $170K in four months; $277K was the price of billing before enrollment.Case study · Emergency departmentHospital ED charge integrity: the hourly ER code that added 20 percent of gross and no cashER visits flat, ER charge units per inpatient account 4.0 to 104.2, 19 to 23% added to gross with no cash: a hospital ED charge-integrity diagnostic.Case study · Emergency departmentER group go-live: the enrollment playbook behind 245 closed-panel claims546 roster lines, 118 billable at go-live, 245 closed-panel claims: the enrollment-routing playbook from an ER group's first four weeks. No cash outcome yet.Case study · FQHCFQHC four-month AR turnaround: 102.8 to 71.3 daysOpen insurance AR down 20.7% from peak, AR days 102.8 to 71.3 with the 18.9/12.6 split disclosed, cash +9.8% a month, $881K from aged claims.Case study · FQHCFQHC payment integrity: right rate, missing visitsPaid exactly the PPS rate on 77% of Medicaid visits, yet $3.13M of billable visits were never paid and $1.93M closed at $0 with no payer decision.Case study · HCC and risk adjustmentHCC chart de-identification: zero PHI leaks on ten real charts, and what that does and does not proveTen real charts, zero leaks on the per-chart scan, 39 regression checks passing: the ASP AI Engine's de-identification boundary. No client outcome claimed.Case study · HCC and risk adjustmentHCC coding engine audit: why a coder still signs offEngine validation only: 1,500 of 1,500 V28 weights matched, a RAF double-count caught and fixed, run-to-run variance disclosed, no client outcome claimed.Case study · HospitalHospital collections up 25.3% like for like, percentage downLike-for-like collections +25.3%, Medicare cash per visit +72%, a record cash month, and a gross collection rate pulled down by one hourly ER charge code.Case study · HospitalHospital growth absorbed: claims up 94%, AR flatClaims submitted nearly doubled to $30.69M a month while insurance AR stayed within 4% and days in AR held at 43; 4.3 touches per claim, $490K untouched.Case study · Behavioral healthBehavioral health denial AR down 54% in four months, and the SLAs still breachingAR behind open denials fell from $1.42M to $656K in four months at a BH and SUD-heavy health center. Three contract SLAs still breached. Both are reported.Case study · Behavioral healthOne encounter, not two: the BH rules that cost a health center cashSame-day E/M plus psychotherapy paid as one encounter on 287 accounts, and a 90-day county carve-out clock behind $419K of past-deadline visits.Case study · Physical therapyPT front desk: 107.7% collected, 3,976 visits shortA 38-clinic PT group collected 107.7% of expected at check-in, yet one visit in ten went short and $158,818 became patient AR; 1,626 visits had no claim.Case study · Physical therapyPT visit-to-claim reconciliation: the 887 claims the AR worklist could not see25,324 PT AR lines joined to EMR visits with 100% date-of-service agreement, 887 open claims missing from the worklist, and 1,626 arrived visits with no claim.Case study · Specialty codingASC orthopedic AI coding pilot, scored by the client's auditorPilot-stage: 79.5% to 86.1% on the client's QA, auditor sided with the engine on 94% of disputed lines, 0 upcoding, one wrong-side catch.Case study · Urgent careUrgent care credentialing: a 29 percent provider-payer gap, 15 declined panels, and credentials that expired while active392 provider-payer lines, 70.9% active, 15 declined group panels, 3 credentials expired while active: a 14-provider urgent care's credentialing review.Case study · Urgent careUrgent care billing: half the cash is the patient, and the gross collection rate is a contract, not a leak27,410 visits, $3.77M cash, 49.1% of it paid by patients, 56.3% gross collection with about 100% net realization, credit balances 1.3x open AR.Case study · Work GenieWork Genie: was the claim worked, or just tagged?Our own spreadsheet-era audit: 47% capture efficiency, 1,059 touches on sub-$100 lines, $139K parked. Now a touch is a submitted record with 24-hour QC.White paper · ABAABA billing for multiple locations: one model for every siteOne payer matrix, one auth ledger, one denial queue. How multi-location ABA groups centralize billing and carry every state rule into 2027.White paper · ABAABA Medicaid rate cuts 2027: the margin playbookIndiana, New York and Nebraska reset ABA Medicaid rates into 2027. Unit capture, clean claims and payer mix: the levers that hold margin.White paper · CorePulseAutomated eligibility verification systems: the 2027 buyer's guideEight criteria and a weighted scorecard: 270/271 depth, thin-271 handling, fallback order, CMS-0057-F API data, benefit maxima, network truth, exceptions.White paper · CredProCredentialing revalidation 2027: one operating model for every cycleMedicare revalidation, CAQH, payer recreds, licenses and the CY2027 retroactive-revocation proposal, run as one calendar with one owner per date in CredPro.White paper · Emergency departmentED facility E/M leveling defense: EDC Analyzer and Anthem G-19002How UHC's EDC Analyzer and Anthem G-19002 re-level facility 99284 and 99285 claims, the exclusions, pre-bill checks and the appeal file that holds in 2027.White paper · Emergency departmentNSA IDR Gateway 2027: an operating manual for ER groupsGateway filing from Nov 13, 2026, web forms closed after Jan 15, 2027, 50-line batches from Nov 1 and the $15 fee: roles, queues and clocks for ER groups.White paper · FQHCFQHC APM vs PPS: the Medicaid decision guideWhen an APM beats PPS, how the at-least-PPS floor is tested, what reconciliation looks like under each path, and the 2026 SPAs with sources.White paper · FQHCFQHC revenue cycle management: the 12-KPI scorecardTwelve measures built for PPS: NCR versus PPS by payer class, wrap recovery and aging, Medicare add-on capture, sliding-fee leakage and front-end inventories.White paper · HCC and risk adjustmentHCC 2027: unlinked chart reviews lose their weightCMS excludes unlinked chart review diagnoses from PY2027 risk scores, built on 2026 visits. The exposure math and nine moves to capture at the encounter.White paper · HCC and risk adjustmentRADV audit response playbook 2027PY2022 audits start January 2027, PY2025 in April. Four phases from the CMS PY2024 instructions: intake, retrieval, checklist validation, discrepancies.White paper · Hospital340B rebate model 2027: hospital cash playbookHRSA's rebate pilot turns the 340B discount on selected drugs into a 45-day, 10-day receivable from January 1, 2027. A pharmacy-to-finance playbook.White paper · HospitalHospital price transparency MRF audit checklist 2027A seven-block self-audit of the machine-readable file after the 2026 changes: access, charges, allowed-amount fields, attestation, display, penalties, the 2027 White paper · Behavioral healthMental health billing services: 2027 buyer's guideParity pause, telehealth in-person rule and the prior authorization API, turned into vendor questions, nine contractable KPIs and a 60-day selection plan.White paper · Behavioral healthMHPAEA parity claims: provider playbook 2026Federal parity enforcement is paused; the statute and your 835s are not. Four exhibits, two arguments in order, and the regulator route for every plan type.White paper · Physical therapyOccupational therapy billing guide 2027Evaluation levels 97165 to 97168, the 8-minute unit table, GO, CO and KX, the OT threshold proposed at $2,540, RTM conditions and RAC topic 0228.White paper · Physical therapyPhysical therapy billing services: 2027 scorecardTen criteria with weights and the evidence to request, each tied to a January 2027 rule: units, KX, plan-of-care clocks, RTM, denials, telehealth, reporting.White paper · Specialty codingCPT 2027 maternity codes: transition playbook for OB groups17 maternity codes deleted, 12 added, antepartum and postpartum care to E/M from January 1, 2027: the code map, the December 31 rules and the January audit.White paper · Urgent careUrgent care after-hours codes 99050, 99051 and 99058: the POS 20 rulebookMedicare bundles every after-hours code, UHC pays two only outside POS 20, Cigna pays two with a condition. The payer table, claim build and contract clause.White paper · Urgent careUrgent care billing services: the 2027 operating manualTwelve controls for urgent care billing: POS 20, S9083 by payer, the CY2027 same-day E/M proposal, telehealth modifiers, front-desk cash, nine KPIs.White paper · Work GenieThe denial management worklist: CARC to root cause, owner and deadlineHow Work Genie reads the 835, maps every CARC and RARC pair to a root cause, owner and deadline, and what the October 1, 2026 code update changed.Newsletter · ABAThe ABA Operator, November 2026: prior auth API countdownMedicaid MCOs and MA plans must run the CMS-0057-F prior-auth API from January 1, 2027. Six questions to ask now, plus Indiana and Blue plan updates.Newsletter · ABAThe ABA Operator, late November 2026: year-end sweepA December sweep of expiring ABA authorizations, plan-year caps to re-verify, and what changes for ABA codes and rates on January 1, 2027.Newsletter · CorePulseThe CorePulse Brief, November 2026: prior auth API day oneIssue 1: the four answers the Prior Authorization API returns from January 1, 2027, who owes them, the clocks you can already enforce, what still needs a call.Newsletter · CredProThe Credentialing Brief, November 2026: retroactive revocation proposalCMS-1844-P would make all revocation grounds retroactive, add denial grounds and a 10-year reapplication bar. The reporting deadlines that now carry money.Newsletter · Emergency departmentThe ED Operator, Issue 2: critical care 99291 documentation that pays99291 from 30 minutes, 99292 after 104 when aggregated or shared, bundled services, modifiers 25 and FS, and the proposed CY2027 conversion factor.Newsletter · Emergency departmentThe ED Operator, Issue 1: IDR batching changes on November 1From November 1, 2026 a batched IDR dispute carries 50 lines and a 30-business-day cooling-off; Gateway filing opens November 13; N877 remits from January.Newsletter · FQHCThe FQHC Operator, late November 2026: the 340B rebate pilotHRSA's 340B rebate model starts January 1, 2027: ten manufacturers, WAC minus ceiling price per unit, 45 days to submit, 10 days to pay, and the data fields.Newsletter · FQHCThe FQHC Operator, November 2026: 2027 PPS rate and telehealthProposed $212.91 Medicare FQHC base rate, telehealth payment through December 31, 2027, G2025 retired, in-person mental health rule not before 2028.Newsletter · HCC and risk adjustmentThe HCC Operator, November 2026: the 2027 Rate Announcement in coding termsCMS kept the 2024 CMS-HCC model, set normalization at 1.079 and 5.90% coding adjustment, and excluded unlinked chart reviews for 2027. Plus a Q1 recapture plan.Newsletter · HCC and risk adjustmentThe HCC Operator, late November 2026: RADV PY2022 kicks off in JanuaryCMS puts PY2022 RADV initiation in January to February 2027, with PY2023 and PY2025 either side. What PY2024 rules tell you, and a 90-day record-readiness plan.Newsletter · HospitalThe CMI, Issue 4: FY2027 MS-DRG shifts and the CDI queueNovember 2026 issue: the FY2027 MS-DRG creations and deletions, the severity designation changes, and the CDI query queue that keeps DNFB flat in Q1.Newsletter · HospitalThe Hospital Cash Cycle, Issue 2: CY2027 OPPS in cash termsNovember 2026 issue: the CY2027 OPPS proposed update, the 340B drug line and offset, site-neutral imaging, prior auth, IPO list and the HPT RFI, each with a CFONewsletter · Behavioral healthThe Mental Health Operator, Issue 1: the parity enforcement pauseNovember 2026: what the May 2025 parity nonenforcement statement does and does not do, the analysis plans still owe, and the auth clocks you can cite.Newsletter · Behavioral healthThe Mental Health Operator, Issue 2: the telehealth POS and modifier map for 2027Late November 2026: POS 10 vs 02, modifiers 95, 93, BB and BC, audio-only conditions and the in-person clock for Medicare behavioral health telehealth in 2027.Newsletter · Physical therapyThe Therapy Operator, November 2026: RTM 2027 rule changesIssue 1: RTM limited to established patients with an initiating visit and employed staff from January 2027 if finalized; modifiers BB and BC; January numbers.Newsletter · Physical therapyThe Therapy Operator, late November 2026: RAC topic 0228Issue 2: the approved RAC review of therapy claims billed with KX, the six-tab response file built from the policies it cites, and the threshold math.Newsletter · Specialty codingThe Coding Operator, November 2026: CPT 2027, 453 changesIssue 1: CPT 2027 by section, the 80 deletions that reject on January 1, the 10 new AI codes and the Appendix S taxonomy, and the December charge master work.Newsletter · Urgent careThe Urgent Care Operator, late November 2026: flu season cash starts at the front deskPeak-volume eligibility at check-in, the payer APIs that feed registration from January 1, 2027, and a self-pay script built on the good faith estimate rule.Newsletter · Urgent careThe Urgent Care Operator, November 2026: the S9083 non-payment mapUnitedHealthcare (Aug 1, 2026 review) and Cigna (Jun 4, 2026 update) list S9083 and S9088 as not reimbursable. The payer map and a four-week migration plan.Newsletter · Work GenieThe Work Genie Brief, November 2026: the October CARC and RARC updateCR 14492 loaded the July 1 X12 lists for October 1 dates of service. Eighteen new RARCs, four that change routing, and the 30-minute diff before November.Guide · ABAABA credentialing services: from BCBA to first paid claimWhat ABA credentialing services do payer by payer: BCBA and RBT enrollment steps, realistic timelines, and the roster gaps that stop billing on day one.Guide · ABAABA gross collection rate: how to calculate itGCR versus NCR for ABA, the formulas, where groups miscount, and how to read the rate after a Medicaid fee-schedule cut.Guide · CorePulseAutomated prior authorization 2027: API, voice or portalThree routes to one answer, sequenced by payer type: the CMS-0057-F API for impacted payers, voice for what no transaction carries, the portal last and logged.Guide · CredProMedicare revalidation: avoid a stay of enrollmentThe revalidation sequence from due-date posting to deactivation, what each state does to claims, and the monthly calendar that prevents the gap.Guide · Emergency departmentAppealing an ED downcode with the prudent layperson standardWhere the prudent layperson standard lives now (45 CFR 149.110), which ED downcodes it answers, the record elements that carry the appeal, and the letter.Guide · Emergency departmentEmergency medicine billing services: what ER groups should demand in 2027Seven standing reports, six No Surprises Act questions, leveling and enrollment controls, and the contract terms an ER group should require before signing.Guide · FQHCFQHC PPS new patient add-on: the 34 percentMedicare pays 34.16% more on new patient, IPPE and AWV visits. The three-year organizational lookback, the one-per-day rule, the math and the fixes by desk.Guide · FQHCFQHC wraparound claim denials: how to fix themFive upstream causes of wrap denials: encounter mismatch, MCO paid-amount gaps, eligibility segments, missing T1015 logic and the wrong rate year, with fixes.Guide · HCC and risk adjustmentHCC suspecting: prospective versus retrospective, and why 2027 picks a sideProspective suspecting produces a documented visit; retrospective review produces a chart review record. From 2027 only one counts on its own.Guide · HCC and risk adjustmentRAF score explained: how it is calculated for 2027Demographic factor, HCC coefficients, hierarchies and interactions, the 1.079 normalization factor and 5.90% coding adjustment, worked on one member for 2027.Guide · HospitalAutonomous inpatient coding: what it coversWhere software can finish an inpatient chart, where the coder still owns it, why MS-DRG logic raises the bar, and the 300-chart accuracy test to run first.Guide · HospitalHospital RCM: what to outsource firstA sequencing guide: aged follow-up first, denials second, front end third, coding only with an accuracy sample, and the functions that should never leave the hoGuide · Behavioral healthBH prior authorization API 2027: what changesCMS-0057-F: Medicaid managed care and MA plans owe a Prior Authorization API by Jan 1, 2027. The 72-hour and 7-day clocks and what moves for therapy.Guide · Behavioral healthMental health billing KPIs for group practicesEight KPIs computed from the 835 with HFMA MAP Key definitions, the CARCs that carry behavioral health denial dollars, and the direction that signals trouble.Guide · Physical therapyKX modifier documentation requirements: the checklistWhat the chart must show before KX goes on: plan of care, 30-day certification, progress reports every 10 treatment days, medical necessity, 2027 math.Guide · Physical therapyOccupational therapy billing codes: 97165 to 97168How the CPT descriptors separate the three OT evaluation levels, when 97168 applies, the Medicare unit table and two worked visits with units counted.Guide · Specialty codingCPT 2027 AI codes: what the 43 codes cover10 new AI codes, 43 in total: the Appendix S taxonomy of assistive, augmentative and autonomous services, and the checks before any AI code is billed.Guide · Urgent careUrgent care billing company vs in-house: the 2027 mathA fully loaded cost worksheet, the control questions that outweigh the fee, and the four 2027 rule changes that test either model. No price list needed.Guide · Urgent careUrgent care RCM KPIs: the nine benchmarks that matterRevenue per visit by billing model, time-of-service collection, first-pass yield, days to bill and five more, each with formula, source and review trigger.Guide · Work GenieClean claim rate: how to calculate and improve itThe clean claim rate formula, the three gates that count, how to set your own benchmark by payer and site, and the five front-end controls that move it.Insight · ABAABA Medicaid rate tracker, Q4 2026 into 2027Dated ABA Medicaid fee-schedule actions in Indiana, New York, Nebraska, Washington, Massachusetts, Montana and North Dakota, each linked to its state source.Insight · ABAABA prior authorization API: MCO readiness for January 1, 2027Which payers must run the CMS-0057-F prior-auth API from January 1, 2027, what it returns, what it leaves alone, and six questions for every MCO.Insight · CorePulseCMS-0062-P: drug prior authorization API by October 1, 2027 (proposed)The April 2026 proposed rule would bring medical-benefit drugs into the FHIR API and pharmacy drugs onto NCPDP standards from October 1, 2027, if finalized.Insight · CredProCY2027 provider enrollment proposals: what changedEvery enrollment provision in CMS-1844-P with its section number: retroactive revocations, new denial grounds, a 10-year reapplication bar, the 36-month rule.Insight · Emergency departmentAnthem's ED leveling policy G-19002: what to auditAnthem's resource-intensity model for facility ED E/M levels, its deny, adjust or recoup rights, four exclusions compared with UHC, and six pre-bill checks.Insight · Emergency departmentUHC's EDC Analyzer ED facility E/M policies: the 2026 readUHC's commercial 2026R6003A and MA 2026R6007A facility ED policies, changed September 1, 2026: the EDC Analyzer inputs, adjustments, exclusions and the audit.Insight · FQHCCY 2027 PFS proposed rule: FQHC and RHC provisionsProposed $212.91 base rate, telehealth payment through 2027, in-person mental health rule not before 2028, and DSMT and MNT as stand-alone RHC visits.Insight · FQHCFQHC Medicaid APM tracker 2026Dated 2026 FQHC state plan amendments: South Dakota medical and dental APM rates, Tennessee APM options, DC rebasing, California, Arizona and Nevada.Insight · HCC and risk adjustmentCMS-HCC 2027 model: what moved, and what CMS shelvedCMS kept the 2024 CMS-HCC model for 2027 and shelved the 2023/2024 recalibration. Normalization moved to 1.079; unlinked chart reviews left the score.Insight · HCC and risk adjustmentRADV audit schedule 2027: PY2022 to PY2025 on one timelineCMS dates: PY2024 started August 28, 2026; PY2023 November 2026; PY2022 January to February 2027; PY2025 April to May 2027. What each asks of a provider group.Insight · HospitalPrice transparency RFI 2027: standardizationWhat CMS asked in the CY2027 OPPS RFI on standardizing price transparency data, how it builds on the 2026 allowed-amount fields, and what to prepare.Insight · HospitalOPPS 2027 prior auth: eight botulinum toxin codesCMS proposes eight more botulinum toxin injection codes for hospital OPD prior authorization from July 1, 2027. The category, the reason, the process, the fix.Insight · Behavioral healthBH telehealth in-person rule: the 2028 countdownNo in-person visit for Medicare home mental health telehealth through Dec 31, 2027. The 6-month and 12-month rules, who is grandfathered, the 2027 plan.Insight · Behavioral healthMHPAEA enforcement timeline, 2026 to 2027Dated parity sequence: 2013 rule, CAA 2021, the 2024 rule, the May 2025 nonenforcement statement, what is on hold and what restarts the clock.Insight · Physical therapyCY 2027 PFS therapy impact: PT, OT and SLPConversion factor down 1.68 percent for most therapy practices, three new RTM conditions, the practice expense shift and a $2,540 KX threshold, all as proposed.Insight · Physical therapyOutpatient therapy denial codes: the CARC mapFifteen reason codes that drive PT, OT and SLP denials after the October 2026 update, each with its remark codes, usual cause, fix and owner.Insight · Specialty codingCY 2027 PFS: same-day E/M and global procedure 50 percent cutTop service at 100 percent, the rest at 50 when an office E/M and a global procedure share a date: CMS's example, the specialties named and your exposure.Insight · Urgent careCY2027 PFS and urgent care: the proposed same-day E/M and procedure cutCMS proposes paying the lower-valued service at 50 percent when an office E/M and a global procedure share a day. The proposal, plus a four-step exposure model.Insight · Urgent careUrgent care virtual visits: POS 10, S9083 and the 2027 modifier changePatient location sets POS 10 or 02, home telehealth pays at the non-facility rate, national payers never pay S9083, and BB and BC arrive January 1, 2027.Insight · Work GeniePayer prior authorization metrics are now public: the 2026 readThe nine measures CMS-0057-F makes payers post by March 31 each year, where to find them, and how to turn them into authorization deadlines and appeals.
Published in October 2026.
White paper · ABAThe silent claim: an ABA operating guide to claim-status follow-upAn operating guide to ABA claims that never get answered: prompt-pay deadlines, a day 21, 35 and 45 status cadence, and remittance coverage tests.White paper · Emergency departmentDefending level 4 and 5 ER visits when payers review every oneAn operating guide for ER groups facing payer reviews of 99284 and 99285: policies by payer, Medicare dollars at stake, MDM proof and the appeal file.White paper · FQHCWho owes the PPS dollar: an FQHC operating guide to payment floors by payer classAn FQHC operating guide to the PPS floor by payer class: Medicaid MCO wraparound, Medicare Advantage supplemental payment, QHPs and commercial plans.White paper · Behavioral healthCCBHC billing in 2026: an operating guide to the four prospective payment optionsAn operating guide to CCBHC billing for the 10 states joining the Medicaid demonstration in 2026: the four PPS options, visit counting, MCO wraps and QBPs.White paper · Physical therapyMedicare outpatient therapy in 2027: the KX threshold operating guideOperating guide to Medicare outpatient therapy in 2027: proposed $2,540 KX threshold, $3,000 targeted review, accrual, MPPR, CQ/CO and RTM proposals.Insight · ABAGeorgia Medicaid ABA rate cuts in 2026Amerigroup cut Georgia Medicaid ABA pay 30% from September 1, 2026, after CareSource and Peach State moves. A dated timeline and three steps for providers.Insight · ABANew York Medicaid halves the technician rate for ABAFrom October 1, 2026 NY Medicaid FFS pays $9.63 per unit for technician ABA (97153), half the $19.26 BCBA rate. What changed and what to do now.Insight · Emergency departmentThe remit will now tell ER groups which claims can go to IDRNine No Surprises Act remark codes take effect Nov 1, 2026 and are required on remits from Jan 1, 2027. What ER groups must change in posting now.Insight · FQHCG2025 is gone for October dates of service: what FQHCs must bill insteadFrom October 1, 2026, FQHCs and RHCs stop billing Medicare distant site telehealth on G2025 and bill the actual CPT code with modifier 95 or 93.Insight · Behavioral healthThe DEA telemedicine cliff: what psychiatry and SUD practices must do before December 31, 2026The DEA special registration final rule went to White House review on Sept 21, 2026. What psychiatry and SUD practices should do before Dec 31.Insight · Physical therapyUnitedHealthcare cut 30% of prior auths on Oct. 1. Your PT auths are still on.UnitedHealthcare cut 30% of prior auth requirements on Oct. 1, 2026. Outpatient therapy comes later. What PT clinics should change now and what to keep.Case study · ABAA multi-state ABA group where the missing money was never deniedA multi-state ABA provider collected 85% of contract value. Our diagnostic found the gap was not denials: $5.05M of claims were never answered.Case study · Emergency departmentAn ER and hospitalist group's first four weeks: enrollment, not coding, was the leakA California emergency medicine and hospitalist group's first four weeks with us: 98.8% registered, 78.8% coded, and enrollment behind 45 of 46 denials.Case study · FQHCA multi-site FQHC network: what the first 70 days found in front of the payerA multi-site FQHC network: what the first 70 days of full revenue cycle work found in its encounter claims, front-end leak and credentialing queue.Case study · Behavioral healthWhat our first 60 days found at a behavioral health and SUD organization: $1.04M of AR waiting on credentialingWhat our first 60 days found at a Mid-Atlantic behavioral health and SUD organization: $1.04M of AR held for credentialing and 52.9% of AR over 90 days.Case study · Physical therapyWhat the first 30 days found in $6.39 million of PT accounts receivableWhat the first 30 days found in $6.39M of AR across 38 outpatient PT clinics: untouched aged claims, paid lines left open, and a filing-window queue.Guide · ABADo RBTs need an NPI? The payer-by-payer answerDo RBTs need an NPI? Federal law alone does not require one, but Optum, TRICARE and Indiana Medicaid now do. Here is the payer-by-payer answer for ABA.Guide · Emergency departmentHospitalist billing guidelines for 2026, admission to dischargeHospitalist billing guidelines for 2026: admit from the ED, observation, same-day discharge, daily visits, G0316 and the Medicare rule behind each code.Guide · FQHCFQHC sliding fee scale 2026: how to build it and bill it cleanlyHow to build an FQHC sliding fee scale for 2026: the HHS poverty guidelines, the 100% and 200% rules, discount bands, and billing it cleanly.Guide · Behavioral healthHow to get credentialed as a therapist: Medicare, Medicaid and commercial panels in 2026How to get credentialed as a therapist with Medicare, Medicaid and commercial panels in 2026: the federal clocks, the filing order and costly mistakes.Guide · Physical therapyThe physical therapy progress report Medicare expects, step by stepPhysical therapy progress report rules for Medicare: the 10-treatment-day rule, who writes it, 90-day recertification and the discharge note.
The August wave · newest 16 of 299
Field note · Aug 15, 2026Stop falling out of network on a missed 120-day attestationField note · Aug 15, 2026Global OB package or itemizeField note · Aug 15, 2026Pediatric Therapy Billing Services: The CPT-Code RulebookField note · Aug 15, 2026The eleven codes the LCDs actually policeField note · Aug 15, 2026The second line is where ASC money quietly leaksField note · Aug 15, 202697155 & 97153 Concurrent Billing DenialsField note · Aug 15, 2026Stop dialing payers. Ask them in EDIField note · Aug 15, 2026Pharmacy DIR 340B Billing 2026: The State NADAC RealityField note · Aug 15, 2026Medical Dental Cross Coding: A CDT-to-CPT Field Guide (2026)Field note · Aug 15, 2026A voice agent that quotes the benefit your claim willField note · Aug 15, 2026What Moved on the CY2026 ASC Covered-Procedures List, andField note · Aug 15, 2026The 2026 payment cut is not a headlineField note · Aug 15, 2026One clinic, two rulebooksField note · Aug 15, 2026Close chronic-condition recapture gaps the chart can defendField note · Aug 15, 2026Surviving RADV Extrapolation: MEAT Documentation That HoldsField note · Aug 15, 2026The drug you throw away is still revenue, if you tag itJUNE 2026 · CASE STUDIES
All case studies →
Five client engagements. Anonymized. With the math.
CS · 01
NEWThree-way match reversed $1.4M of post-pay takebacks.
Authorization, supervision ratio, EHR note at one pre-submit gate. Zero auth-expired sessions for 12 months.
$1.4MReversed
CS · 02
NEWWrap reconciliation surfaced $2.1M in interim limbo.
Member-encounter reconciliation against published PPS rate. 4,800 unpaid wrap entries recovered in 11 weeks.
$2.1MWrap recovered
CS · 03
NEWDNFB compressed 11d to 4d. $4.8M cash unlocked.
Critical-access hospital, Meditech Expanse. CDI loop closed, payer-rule library built, twice-daily DNFB huddle.
4dDNFB steady-state
CS · 04
NEWBCBA enrollment cut from 97 days to 22.
14-state ABA chain, 38 BCBAs. Parallel commercial + Medicaid. $1.52M revenue captured that would have sat in limbo.
22dBCBA TAT median
CS · 05
NEWV28 RAF lift +0.14. $5.8M PMPY recovered.
MA practice, 18-month encounter sample. V28 condition map, suspect generation, recapture campaign, AWV completion.
+0.14RAF lift, 90d
JULY 2026 · WHITE PAPER SERIES
All white papers →
The ABA Revenue Engine. Five papers, one system.
SERIES · 01
NEWThe Authorization Ledger: utilization is the master metric.
Approved hours expire silently. The five-step ledger that holds utilization at 85 to 95 percent with zero lapsed days.
Paper 01Reference
SERIES · 02
NEWThe Payer You Cannot See: eligibility and COB defense.
Insurance changes silently mid-episode. The monthly sweep that caps recoupment exposure at one month, not twelve.
Paper 02Reference
SERIES · 03
NEWUnit Economics of the Session: clean claim engineering.
A clean claim costs $1x, a rework $8x, an appeal $25x. The 97151 to 97156 family engineered to clear first pass.
Paper 03Reference
SERIES · 04
NEWFifty-Two Jurisdictions, One Claim: multi-state compliance.
Expansion multiplies the rule surface faster than revenue. The versioned rule library that replaces memory.
Paper 04Reference
SERIES · 05
NEWThe Escalation Ladder: denials as negotiation, not queue work.
Four rungs from payer rep to state regulator, with the regulatory case where 100 percent of denials were overturned.
Paper 05Reference
JUNE 2026 · WHITE PAPERS
All white papers →
Five open-access references. No email gate.
WP · 01
NEWThe CMS V28 playbook for risk-adjustment coding teams.
2,300 ICD-10 codes re-weighted, 200+ removed, 8-step migration timeline for MA and ACO REACH.
4,209wReference
WP · 02
NEWThe three-way match handbook for ABA billing teams.
Auth tracking, supervision ratio, EHR note matching across 97151-97158. The 20 Pre-Flight Validator rules.
4,306wReference
WP · 03
NEWNCR over GCR: an honest collection framework for FQHCs.
Why GCR misleads under PPS. NCR by payer class. AR aging on date-of-service. T1015 denial taxonomy.
4,402wReference
WP · 04
NEWThe 80 denial patterns reference for RCM operations.
80 active denial root causes. Per pattern: CARC/RARC, payer mix, prevention rate, recommended correction.
4,308wReference
WP · 05
NEWCutting BCBA credentialing from 97 days to 22.
Parallel commercial + Medicaid pipelines, NPPES auto-enrich, BACB lookup, Pre-Flight Validator, RS256 Passport.
4,303wReference
MAY + JUNE 2026 · NEWSLETTER ISSUES
All newsletters →
Three franchises. Five fresh issues.
NL · 01
NEWAuthorization gaps and the recapture playbook.
Auth-expired session billing is the largest preventable category in ABA. Six-step recapture playbook. Pre-Flight gate.
Jun 20269 min read
NL · 02
NEWRAF attribution: where the lift actually comes from.
Suspect-driven +0.041, recapture +0.058, gap closures +0.024, new diagnoses +0.017 equals +0.14 RAF.
Jun 20269 min read
NL · 03
NEWDRG drift: catching the silent capture loss.
CMI compression patterns 2024-2026. Sepsis DRG nuance. Medical-necessity documentation as the CMI lever.
Jun 20269 min read
NL · 04
NEWMedicaid rate cuts, credentialing, parent A/R.
Medicaid ABA rate cuts are spreading. BCBA credentialing still runs 90 to 120 days. Parent A/R DSO at 58 days. What to do.
May 20269 min read
NL · 05
NEWV28 condition map shifts and the recapture window.
V28 dropped 200+ codes, re-weighted 2,300. The recapture window is tighter than most practices realize.
May 20269 min read
Publishing log
What landed when. In order.
Oct 27 · 2026
Content and matrix upgrade: 100 new case studies, white papers, newsletters, guides and insights across ABA, behavioral health, physical therapy, FQHC, hospital, emergency department, urgent care, HCC and specialty coding, CorePulse, CredPro and Work Genie, the refreshed payer policy matrices and the new hospital payer matrix.
Oct 3 · 2026
October upgrade: new emergency department billing page and 50-state ER payer matrix, the October refresh of the payer policy matrices, the RCM terms and acronyms A to Z, and 20 new pieces listed above.
Jun 20 · 2026
What's New hub published. Single index for the June publishing wave. Bookmark this page.
Jun 17 · 2026
5 white papers shipped: V28 HCC Playbook, ABA Three-Way Match Handbook, FQHC NCR Framework, 80 Denial Patterns Reference, BCBA Credentialing TAT Compression.
Jun 16 · 2026
5 case studies shipped, anonymized with the math: ABA three-way match, FQHC wrap reconciliation, hospital DNFB, BCBA credentialing, V28 RAF lift.
Jun 15 · 2026
Newsletter wave: The ABA Operator Issue #2, The HCC Operator Issue #2, The CMI Issue #2. The Issue #1 editions were also expanded.
Dec 20 · 2025
ASP 6th Annual Celebration blog with the photo gallery. Read the recap →
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