VAB RCM

10/18/2026

AI is the dominant force in medical billing right now, accelerating both coding intensity and administrative efficiency while raising short-term costs, alongside major efforts to cut credentialing duplication and recent code-set updates that took effect October 1.

Artificial intelligence is reshaping revenue cycle management (RCM), claims processing, coding, and patient collections. Adoption is high: 88% of surveyed health systems were using AI internally (with 71% having pilots or full deployments in finance/RCM), per HFMA data.

CMS Administrator Dr. Mehmet Oz has warned that AI will be inflationary in the short term because it “turbocharges” existing billing systems—enabling more complete diagnosis capture and higher-intensity coding—before delivering longer-term efficiencies (e.g., via accountable care models). This aligns with a Blue Cross Blue Shield Association analysis (released around late September 2026) estimating that increased coding intensity added about $942 million in costs to Blue plans from 2023–2025. Roughly 70% (~$653 million) came from secondary diagnoses (“bump codes”) that shifted claims into higher-paying categories, without corresponding increases in treatment intensity. More than 60% of hospital systems had adopted AI coding tools that scan records, labs, and notes. The share of inpatient stays coded as complex rose from ~37% (early 2023) to ~40% (late 2025).

On the collections side, AI personalization (e.g., Cedar’s platform) has shown gains—one case study reported a 42% rise in patient collection rates. Medical debt remains widespread: 27% of U.S. adults reported personal or family medical debt as of late 2025 (Urban Institute/RWJF).

americanhealthcareleader.com/2026/how-ai-is-reshaping-medical-billing-and-hospital-revenue/

10/13/2026

A Proposed Bill Could Change How Out-of-Network Medical Claims Are Paid

A bill introduced in the U.S. House of Representatives could substantially change how providers and insurers resolve out-of-network payment disputes. The Lower Premiums, Faster Payments Act (H.R. 10788) would end the federal independent dispute resolution process for services furnished beginning January 1, 2028, and generally use a defined payment benchmark instead.

This is a proposal, not a change to current billing rules. The bill was introduced on October 9 and has been referred to House committees.

How does the current process work?

The No Surprises Act protects patients from certain unexpected out-of-network bills, including many emergency services and services provided by an out-of-network clinician at an in-network facility. It also provides a way for insurers and providers to resolve disagreements over payment without placing the disputed balance on the patient.

After an insurer issues an initial payment or payment denial for an eligible claim, the parties can enter a 30-business-day negotiation period. If they cannot agree, either party may start independent dispute resolution, commonly called IDR. Both sides submit a proposed payment, and an independent organization selects one of the offers.

What would the bill change?

For services furnished from January 1, 2028, the bill would eliminate that federal arbitration route. Where its proposed federal payment rule applies, the out-of-network rate would instead be the qualifying payment amount, or QPA.

The QPA is broadly based on an insurer’s median contracted rate for comparable services in the relevant specialty and geographic area, adjusted for inflation. The bill would revise how that amount is calculated for 2028 and later years. It also proposes a 30-day payment deadline after the provider transmits the bill when the QPA determines the out-of-network rate.

Consider a claim for which a provider believes $1,500 is appropriate but the applicable QPA is $1,000. Under today’s federal process, an eligible provider may negotiate and then seek an IDR decision on the total payment. Under the proposal, that arbitration path would no longer be available for a service furnished from 2028; the applicable payment benchmark would generally be the QPA. The insurer’s payment and the patient’s permitted cost sharing are parts of that total amount. The $500 difference in this example would not become a surprise bill to the protected patient.

Why does this matter for medical billing?

For billing and revenue cycle teams, the focus could shift from preparing IDR submissions to checking whether the insurer calculated and applied the correct QPA. That would require careful attention to the service code, provider specialty, geographic area, plan information, claim classification and payment timing.

The proposal does not cover every out-of-network claim. The federal No Surprises Act applies to defined categories of services, and an applicable state law or other payment arrangement can determine the rate in some cases.

Providers should continue following current negotiation and IDR rules. The bill has not passed, and federal agencies would still need to develop parts of the revised QPA methodology if it became law. For now, it is a significant proposal to watch, especially for organizations with a high volume of eligible out-of-network claims.

https://www.govinfo.gov/app/details/BILLS-119hr10788ih?utm_source=chatgpt.com

10/05/2026

Beginning October 1, hundreds of thousands of lawfully present immigrants may lose Medicaid coverage under the 2025 One Big Beautiful Bill Act. State data reviewed by KFF Health News identifies more than 281,000 people at risk across nine states and Washington, D.C., including refugees, asylees, trafficking victims, and Afghan interpreters. Florida accounts for nearly 177,000. Further restrictions on Affordable Care Act subsidies and Medicare are expected in 2026. Some states, including California, New York, and Pennsylvania, are funding replacement coverage.

Read this article and Watchmen analysis from The Watchmen.

09/28/2026

CMS published preliminary 2027 Medicare laboratory payment rates. CMS estimates the proposed alignment with private-payer rates would save about $1 billion annually. Comments are open for 30 days; CMS expects final rates in November and an effective date of January 1, 2027. These are preliminary rates, not a payment change already in force.

CMS Announces New Preliminary Medicare Payment Rates for Laboratory Services, Saving Taxpayers an Estimated $1 Billion Annually

09/24/2026

AI maker Anthropic has announced the discovery of a new enzyme system in bacterial DNA that it said could “represent a new gene editing mechanism” similar to the groundbreaking CRISPR

//thenextweb.com/news/anthropic-claude-enzyme-system-crispr-like-repeats

An AI agent spotted DNA repeats by eye and led Anthropic to a new enzyme system. What the system does is still unknown.

09/21/2026

A new centralized platform by the Centers for Medicare & Medicaid Services for managing federal independent dispute resolutions related to the No Surprises Act opened Sept. 15. The Independent Dispute Resolution Gateway allows users to start and respond to disputes; access dispute dashboards and reports associated with their organization; track dispute information, including those assigned to a certified IDR entity; monitor assigned disputes by process phase; and review notifications regarding dispute activity. CMS said that organizations and individuals that process disputes, represent parties or submit IDR web forms under the current federal IDR process must sign up for the IDR Gateway.

A new centralized platform by the Centers for Medicare & Medicaid Services for managing federal independent dispute resolutions related to the No Surprises Act opened Sept. 15.

09/18/2026

On September 15, Reuters reported that Waystar, one of the largest healthcare payment and RCM technology companies, had retained Evercore and Barclays to examine strategic alternatives, including a possible sale. Its market value was approximately $5.2 billion, and its shares rose more than 8% following the report.
Waystar operates claims management, payment, denial-prevention and administrative-automation systems used by providers and health systems.

Software provider Waystar , whose products are used by hospitals and doctors to manage payments, is exploring options including a potential sale that could return it to private hands two years after a stock market ​listing in New York, seven sources familiar with the matter said.

09/06/2026

About 1 in every 5 eligible adults in Medicaid expansion states might lose their benefits due to new work requirements that take effect in 2027, a new study says. These folks likely will be unable to fulfill the minimum work hours required under the new law,

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08/29/2026

Medicare Advantage coding enforcement is becoming a very serious financial risk. On August 28, The Villages Health agreed to a $541.5 million settlement over allegations that unsupported diagnosis codes were submitted and thereby increased Medicare Advantage payments. This is directly relevant to coding, risk adjustment, compliance audits, and billing documentation.

The settlement resolves allegations that the Humana-owned provider submitted unsupported diagnosis codes that increased federal payments.

08/17/2026

The latest available U.S. data (July 2026) for the major inflation and medical-cost indexes comparison. Can medical billing beat inflation?

The July numbers show that headline inflation eased very slightly: CPI rose 0.1% in July and 3.4% year-on-year, down from 3.5% in June. Core inflation, excluding food and energy, rose 0.2% month-on-month and 2.5% year-on-year. Energy remains unusually inflationary, up 14.7% from July 2025, although energy prices actually fell 1.5% during July.

Medical prices moved rather differently from the general index. The broad medical-care CPI increased 0.4% in July alone, after falling 0.1% in June. Within medical care, hospital services rose 0.5% in July, physicians' services rose 0.2%, while prescription-drug prices fell 0.8%. Medical-care services as a whole rose 0.6% in July and 2.7% over the preceding 12 months. The broader medical-care index was up 1.7% year-on-year.
So there is an interesting distinction: medical care overall is currently rising more slowly year-on-year than general CPI (1.7% versus 3.4%), but medical-service prices accelerated sharply in July, particularly hospital charges. Medical-care commodities, by contrast, were actually 2.7% cheaper than a year earlier and fell 0.6% in July.

There is also a longer-running hospital-cost problem that the headline medical CPI partly conceals. PwC's latest 2026 analysis reports that hospital and related-services inflation reached 7.59% year-on-year in February 2026, a post-pandemic high. In other words, the amount ultimately charged or negotiated for hospital care can be rising substantially faster than the broad consumer medical-price index.