Category: RCM

CMS Promoting RPM by Adding New Codes in 2026

by hws2022, posted in RCM

CMS Promoting RPM by Adding New Codes in 2026

      • RPM adoption remains limited: Only 30% of U.S. physicians used remote patient monitoring in 2022 (AMA Digital Health Study).

Why RPM Lagged in Real Practice

      • Reimbursement uncertainty & complex billing: Strict transmission-day minimums, evolving CPT rules, and heavy documentation made adoption difficult.
      • High upfront costs & tech barriers: FDA-cleared devices, HIPAA-secure platforms, and EHR integration were expensive and challenging for small clinics.
      • Workflow burden & staffing constraints: Continuous data review, patient check-ins, and documentation required more staff than many practices could allocate.(Prevounce)

New CMS Codes (Effective 2026)

      • CPT 99445 (~$47): Covers 2–15 days of short-term RPM data in a 30-day period.
      • CPT 99470 (~$26): Covers first 10 minutes of monthly RPM management plus one real-time patient interaction. (Prevounce)

Impact:

      • Lower entry threshold for small practices
      • Flexible billing aligned with real-world clinical workflows
      • Expanded access across primary care, cardiology, endocrinology, nephrology, geriatrics

Real-World Outcomes & ROI

1,000-Patient Chronic-Care Panel

      • Panel: 300 CHF, 350 diabetes, 350 hypertension 
      • Clinical impact: 
          • ~20% reduction in CHF hospitalizations (PMC10424885) 
          • Improved diabetes & hypertension control (PubMed39974005) 
          • Increased patient engagement via real-time feedback & monthly interactions 
      • Financial & operational impact (current codes): 
          • Program cost: ~$500/patient/year 
          • Revenue: ~$700K/year 
          • Savings from avoided acute events: $400K–$600K 
          • ROI: ~20–40%, including AI-driven efficiency 
      • Projected impact with 2026 codes: 
          • Revenue: ~$900K–$1.1M/year 
          • ROI: ~300–500% 
          • Sustained improvements in chronic-disease management, lower hospitalizations, better patient adherence

Takeaway: RPM not only increases revenue but directly enhances patient health and quality of care, making it a clinically and economically valuable strategy.

Contact: contact@medicalofficeforce.com

References:

How to Use Remote Patient Monitoring for Obesity & Weight Loss

by hws2022, posted in RCM

How to Use Remote Patient Monitoring for Obesity & Weight Loss

Obesity affects over 42% of U.S. adults, increasing the risk of diabetes, heart disease, and other chronic conditions. Traditional care often loses momentum between visits, but Remote Patient Monitoring (RPM) helps bridge that gap. (CDC)

Why physicians often struggle to achieve consistent patient outcomes

      • Time constraints: Typical visits last 10 to 15 minutes, leaving limited scope to explore dietary patterns, sleep health, and psychological triggers in depth.
      • Biological complexity: Obesity is often treated as a lifestyle issue rather than a neurohormonal and metabolic condition that requires medical intervention.
      • Irregular follow-up: Without structured continuity, patients lose motivation, and small lapses quickly reverse progress.
      • Underuse of technology: Many practices still rely solely on in-person check-ins, missing opportunities for remote monitoring, automated feedback, and patient accountability.

Building a more effective clinical model for obesity care

      • Begin with a structured baseline evaluation.
        Go beyond BMI to assess waist circumference, visceral fat indicators, sleep patterns, mental health, medication-related weight gain, and past weight-loss attempts.
      • Set realistic, collaborative goals.
        Define measurable milestones that feel achievable for the patient, for instance, a 5 percent weight reduction in three months or a daily step target of 7,000.
      • Combine behavioral coaching and evidence-based therapy.
        Motivational interviewing, meal structure planning, and small daily changes often outperform drastic diet restrictions. When appropriate, incorporate FDA-approved anti-obesity medications.
      • Address underlying sleep and mental health issues.
        Depression, insomnia, stress eating, and obstructive sleep apnea all contribute to metabolic dysregulation.
      • Maintain consistent follow-up frequency.
        Patients are most successful when they receive regular reinforcement, biweekly touchpoints initially, tapering to monthly check-ins once weight stabilizes.
      • Early feedback enables timely course correction before motivation declines.

How Remote Patient Monitoring changes the trajectory of weight management

RPM allows physicians to:

      • Track real-time changes in weight, blood pressure, and activity levels. 
      • Provide structured weekly feedback that reinforces accountability. 
      • Identify plateau phases early and modify care plans proactively. 
      • Increase adherence through consistent digital touchpoints rather than waiting for the next appointment

Proven results by RPM

      • Digital monitoring plus feedback: Tracking weight with real-time coaching improves adherence and long-term outcomes (PMC4380831). 
      • Behavioral changes: Continuous data keeps patients accountable between visits. 
      • Durable impact: Clinically supervised digital programs support lasting weight maintenance (CDC Adult Obesity Facts).

Current CPT codes such as 99453, 99454, 99457, and 99458 support reimbursement for setup, device transmission, and interactive communication, helping practices sustain high-quality, continuous care. CMS RPM guidance.

The role of Medical Office Force in supporting clinical implementation

Medical Office Force supports practices in building effective RPM programs, compliant billing, and real-time data visibility. 

Our RCM and clinical support services are designed to reduce administrative load, help improve the accuracy of documentation, and make sure patients receive consistent, connected care.

References

AI Integrations in EHR: A look into 2026

by hws2022, posted in RCM

AI Integrations in EHR: A look into 2026

Artificial intelligence is changing the way medical records are kept, diagnoses are made, and medical treatments are delivered. In 2026, AI in electronic health records will advance beyond mere automation to create intelligent, proactive clinical systems that support physicians and patients. 

These changes improve workflows and decision-making, all while bolstering the quality of patient outcomes with firm commitments to privacy and data ethics.

Yet, this progress also depends on surmounting some of the long-standing challenges in data interoperability, cost, and governance. 

Understanding how AI is changing electronic health records helps us appreciate not only what’s changing today in clinical practice but also what lies ahead for a smarter, more connected healthcare future.

Advancements in Clinical Workflows

The most prominent change in 2026 involves the use of AI-powered clinical assistance that will facilitate the creation of documentation and sharpen diagnostic acumen.

Ambient clinical intelligence systems now use natural language processing to listen during doctor-patient conversations and automatically generate accurate, structured notes in real time. This advancement saves clinicians valuable time, reduces errors, and plays a major role in addressing physician burnout, a growing concern across all healthcare settings.

Enhanced clinical decision support (CDS) tools are another area of rapid progress. These systems integrate data from multiple sources, including imaging, lab results, and even genomic markers, to provide real-time diagnostic insights. The goal is not to replace the clinician’s judgment but to offer deeper, faster, and more evidence-based recommendations for complex cases.

Diagnostic integration in multi-modalities is especially impactful in fields like oncology and cardiology. For instance, integrating pathology slides, imaging data, and genetic information into a single analysis using AI enables a more holistic understanding of diseases and helps physicians select personalized treatment pathways.

Administrative Efficiency and Smarter Operations

AI is also reshaping the administrative aspects of healthcare, usually considered the most time-consuming part of clinical practice.

Now, automated billing and coding systems review clinical documentation, apply appropriate medical codes, and flag inconsistencies before submission. 

This reduces billing errors, shortens reimbursement cycles, and ensures compliance with insurance requirements.

Intelligent scheduling tools are being implemented across hospitals and clinics to predict patient no-shows, manage provider workloads, and optimize appointment flow. 

These systems learn from past patterns to make the process more efficient and patient-friendly.

Another trend that is on the rise is automated prior authorization. AI can today manage many routine approval requests and even process appeals when necessary. This improvement saves hours of manual work by administrative teams and ensures timely access to care for patients.

Patient-Centered Care and Predictive Health

Predictive health analytics identify patients who are at risk for conditions such as sepsis, heart disease, or hospital readmission by analyzing trends in EHR data. These systems enable providers to intervene earlier, shifting from reactive to preventive care.

AI-powered patient portals are evolving as well. Instead of serving only as record-keeping tools, they now deliver tailored health insights, automated medication reminders, and intelligent chatbots that help patients manage follow-ups or understand lab results more easily.

RPM integration has also become seamless. Wearable devices and connected sensors feed data directly into the EHR, giving clinicians a continuous view of every patient’s health and allowing real-time alerts when irregularities arise. This level of connectivity supports better chronic disease management and reduces hospital visits.

The Future of EHRs in 2026 and Beyond

The EHR landscape of 2026 is defined by smarter, more collaborative systems, not isolated ones.

The widespread adoption of the FHIR standard makes data sharing among providers more seamless, thus ensuring continuity in transitions of care and a single patient record across systems.

A major trend is the shift toward explainable AI, or XAI. With algorithms increasingly at the center of clinical decisions, healthcare regulators are demanding transparency into how these tools arrive at recommendations. Hospitals and developers are responding with governance frameworks that ensure that AI is safe, ethical, and accountable.

Other key characteristics include privacy-first innovation. Federated learning is one example of how AI models can learn across many healthcare organizations without actually pooling sensitive data in a single location. This keeps patient confidentiality intact while still supporting model accuracy and large-scale research.

The future role of AI in EHRs is essentially that of a co-pilot: to enhance clinical efficiency, accuracy, and ultimately patient outcomes, while leaving the human touch of care firmly in the hands of physicians.

How Medical Office Force Supports a Smarter, Patient-Focused Future

We believe that technology should enhance and not complicate patient care. Our staff keeps aligned with the latest advancements in health care innovation so that tools like EHRs and AI integration are applied in a safe, efficient, and ethical way. The focus remains on supporting each patient’s journey toward better health through accurate information, coordination of care, and trusted clinical relationships.

10 Ways to Improve Medical Practice Management

10 Ways to Improve Medical Practice Management

by hws2022, posted in RCM
10 Ways to Improve Medical Practice Management

10 Ways to Improve Medical Practice Management

Running a successful medical practice involves more than providing care, it requires effective management of daily operations, finances, and patient interactions. Improving practice management helps streamline work, reduce unnecessary delays, and support better patient outcomes. Here are 10 ways practices can enhance their management in 2025 and beyond.

1. Embrace Revenue Cycle Automation

Leveraging automation for things like eligibility checks, claims calls, payment posting, and follow-ups means one isn’t leaving money on the table or losing staff hours to mindless double-entry. 

Modern RCM tools free up team bandwidth for real human interaction, so the billing desk becomes part of the care experience, and not only paperwork. These automations will also help one to decrease errors and speed up cash flow.

2. Invest in Smart Scheduling Systems

Missed appointments bleed revenue, while wasted appointment slots directly cut into productivity.

Syncing the digital scheduling with patient reminders across SMS, email, or even app notifications. Features like real-time rescheduling or waitlist-filling boost the capacity usage. 

Timely checking analytics helps evaluate the scheduling data and can reveal peak times and hidden inefficiencies. When one optimizes the system,one gives patients flexibility, decreases bottlenecks, and keeps providers working at the top of their licenses.

3.Tracking Performance Metrics

What all gets measured, gets managed. Developing dashboards to keep tabs on accounts receivable (AR) days, denial rates, patient waiting times, helps to increase productivity. 

Cross checking the metrics regularly, comparing performance across sites or providers, and digging into trends. 

With timely access to the data, one can spot potential problems before they spiral, whether that’s a claim backlog, a process break, or waning productivity in a specific location. Data-driven decisions are the difference between sustainable growth and costly mistakes.

4. Improving the Patient Experience

In a saturated healthcare environment, great care isn’t enough. One needs a seamless experience from the first touchpoint, think user-friendly online booking, efficient digital check-ins, transparent communication, and timely follow-up. 

Implementing patient-reported outcome surveys to close service gaps and reinforce loyalty. Investing in hospitality training and staff empathy can supercharge retention and turn happy patients into vocal advocates for the practice.

5. Integrating Telemedicine and Remote Patient Monitoring

Telehealth is now standard, not a novelty. Layer in remote patient monitoring for chronic conditions to support better long-term outcomes and reduce acute episodes. This tech lets one extend the reach to patients who’d otherwise skip follow-ups, and offers data for proactive interventions. On the business side, it opens up new revenue streams and can make the practice much more scalable, especially in underserved markets.

6. Put Cost Transparency Front and Center

Equipping the front desk and financial staff with clear scripts and tools for providing upfront cost estimates and payment plans. Making price lists accessible for common procedures, and adopting digital payment tools to make transactions easy and secure. Transparent policies reduce payment delays, boost patient confidence, and protect the reputation.

7. Prioritizing Staff Training

Clinical and admin teams are the heart of the practice. Ongoing training, whether in compliance updates, new EHR features, customer service, or teamwork, prevents costly mistakes and preserves morale. Develop a continuous learning culture: offer regular workshops, e-learning resources, and feedback loops. When one invests in the people, they invest back in the business. High staff competency means better patient care and more efficient ops.

8. Engage in Continuous Quality Improvement (CQI)

CQI isn’t just a regulatory checkbox, it’s an avenue for true competitive advantage. Design workflows to collect and act on patient feedback, regularly map out process bottlenecks, and leverage team brainstorming sessions for innovation. Incorporate data into every step, and use small pilot projects to test changes before scaling. Over time, these incremental improvements add up, translating to measurable gains in efficiency and outcomes (and often, cost savings).

9. Ensure Compliance and Data Security

A data breach or compliance fine is every manager’s nightmare, not to mention the reputational fallout. Don’t just check the box for HIPAA. Invest in next-gen cybersecurity solutions, data encryption, staff cyber-training, and periodic audits. Create a culture where reporting risks is celebrated, not punished. Protecting the client data isn’t just ethical, it’s crucial for keeping the doors open and maintaining patient trust in the digital age.

10. Develop a Robust and Modern Online Presence

Patients, especially younger demographics, shop for healthcare like anything else: online. Build a professional, intuitive website; update the Google and social media profiles; and maintain an active presence so the practice stands out. Make sure patient portals provide real value, secure messaging, lab results, scheduling, billing. A strong online footprint is as important as the physical front desk, it drives new business and improves ongoing patient engagement.

Final Thoughts for the Business-Minded Medical Manager:

It’s about building workflows that serve the team and the community, capturing efficiencies with smart tech, and treating data and relationships with equal care. 

The practices that adapt, measure, and iterate will be the ones that stay profitable and resilient, no matter what the next year throws their way. Now, go turn these bullets into the business plan.

Tips for Better Practice Management

by hws2022, posted in RCM

Tips for Better Practice Management

It’s not an easy business having a medical practice. Between caring for patients, paperwork, and employee management, everything becomes stressful. That’s why enhanced business management of your practice is beneficial; you will save time, feel less stress, and ensure your practice’s financial sustainability.

Practice management is simply getting your office running smoothly, whether that’s front-office operations like schedule-setting and checking-in, or back-office operations like billing, referring, and follow-up of patients. Done right, it allows you to focus on what’s most important: your patients.

Some practical, down-to-earth advice, and how Medical Office Force can assist you every step of the way.

1. Work Smarter by Using Technology

The appropriate software will reduce errors and give you a break from your time.

      • EHR systems store every detail of patients in one location.
      • Practice management software makes scheduling and billing easier.
      • Telehealth platforms extend your reach while reducing no-shows.

At Medical Office Force, we make integrating these tools straightforward so you can focus on care rather than troubleshooting.

2. Patient Communication Facilitation

 Patients like clear, simple communications. Some possible strategies:

      • Hand out pamphlets or digital manuals on medications and treatment.
      • Offer an easy-to-use patient portal for scheduling and messaging.
      • Collect feedback from reviews on the internet.

Medical Office Force supports your improved patient experience by providing software that enables efficient and simpler communications.

3. Strengthen Your Revenue Cycle

Cash flow is your business’s lifeline. Delays of a few days here will generate huge headaches.

      • Pre-aute every visit to prevent denied claims.
      • Collect co-pays at check-in.
      • Make use of automated billing to minimize errors.
      • Track financial metrics regularly.

Our team provides revenue cycle management so that your practice will continue to be financially robust.

4. Stay Compliant Without the Stress

Healthcare guidelines always evolve. Protect your practice by:

      • Following HIPAA guidelines for patient data.
      • Training employees on compliance issues regularly.
      • Keeping audit-ready documentation.

Medical Office Force offers continued support so you never need to worry about getting left behind.

5. Let Data Guide Your Decisions

 Numbers hold stories. From analyzing data patterns, you can:

      • Identify when peak volume for best scheduling occurs.
      • Recognize common causes of claim denial.
      • Identify areas for enhanced patient education.

Medical Office Force analytics offers you insightful clarity that you make good decisions.

6. Develop a Marketing Plan That Performs

Excellent practices need exposure. It only involves a few steps:

      • Make your site search engine-friendly.
      • Share valuable content on social media.
      • Encourage patients to leave reviews.

Medical Office Force differentiates practices with patient-attraction strategies that also improve patient retention.

7. Improve Care with RPM & CCM

Modern care doesn’t stop at the office door.

      • Remote Patient Monitoring (RPM): Remotely monitors patients at home, reduces hospital visits, and maximizes outcomes.
      • Chronic Care Management (CCM): Encourages enhanced patient relationships with ongoing care and Medicare-covered reimbursements.
         Medical Office Force offers ready-to-deploy RPM and CCM solutions that help you provide best-in-class care while enhancing revenues.

Why Better Practice Management Matters

When you make your practice more effective, we all benefit:

      • Better care is given with lower hospitalizations.
      • Employees work with lower stress and greater clarity.
      • Your practice becomes stronger, more profitable, and friendlier towards patients.

How Medical Office Force Can Help

At the Medical Office Force, we make practice management easy. From billing support and revenue cycle management to RPM programs and CCM programs, we do everything we can to ease your burden while building your bottom line.

If you’re ready to:

      • Reduce costs
      • Increase revenue
      • Enhance physician satisfaction

Arrange a consultation with us today. Unlock your practice’s potential for continued success with the Medical Office Force.

AI in Care Coordination: How Small Clinics Can Compete with Health Systems

AI in Care Coordination: How Small Clinics Can Compete with Health Systems

by hws2022, posted in RCM
AI in Care Coordination: How Small Clinics Can Compete with Health Systems

Tips for Better Practice Management

In today’s fast-changing healthcare environment, care coordination has become one of the most important elements of patient-centric care. For large health systems, managing care across different providers, specialties, and facilities is easier because they have access to advanced technology, robust IT systems, and larger care teams.

But what about small clinics and independent practices? Many smaller organizations often feel left behind, struggling with limited resources, staffing shortages, and the constant challenge of keeping patients engaged and connected.

Here’s the good news: Artificial Intelligence (AI) is changing the game. With smart, affordable solutions, even small clinics can improve care coordination, reduce administrative work, and deliver the same level of advanced care as large health systems, sometimes even better.

This blog reflects on how AI is reshaping care coordination, why it matters for small clinics, and how your practice can embrace these tools to compete effectively.

Why Care Coordination is Critical

Care coordination is all about making sure patients receive the right care, at the right time, without gaps or duplication. According to the Agency for Healthcare Research and Quality (AHRQ), care coordination is one of the key strategies for achieving safer, more effective, and more efficient healthcare.

When care is poorly coordinated, it often results in:

  • Missed follow-ups or delayed treatments
  • Patients falling through the cracks between providers
  • Duplicated tests and procedures
  • Higher hospital readmission rates
  • Increased costs for both patients and clinics
  • Lower patient satisfaction and trust

For smaller clinics, the challenge is greater because staff often wear multiple hats, handling administrative tasks, clinical care, and patient engagement all at once. Without strong systems, it’s easy for patients to get lost in the shuffle.

This is where AI-driven care coordination becomes a powerful ally.

How AI is Transforming Care Coordination

AI does not replace doctors, nurses, or staff, it empowers them. By automating routine tasks, analyzing large volumes of data, and predicting patient needs, AI allows clinics to focus on what really matters: personalized patient care.

Here’s how AI can make a difference:

1. Smarter Scheduling and Patient Reminders

Missed appointments cost U.S. healthcare billions every year. According to the Centers for Medicare & Medicaid Services (CMS), patient engagement is a major factor in care quality. AI-driven scheduling tools can:

  • – Predict which patients are most likely to miss appointments
  • – Automatically send reminders via text, email, or calls
  • – Optimize appointment slots to reduce wasted time

     

For small clinics, this means higher patient attendance rates and smoother workflows.

2. Personalized Care Plans

Every patient is different. AI can analyze medical history, lab results, and medication records to help create care plans for each individual. For example, AI tools can:

  • – Identify chronic conditions that need closer monitoring
  • – Suggest lifestyle changes based on patient history
  • – Provide clinicians with real-time recommendations

     

This level of personalization helps small clinics deliver big-hospital-level care without needing a huge staff.

3. Predictive Analytics for Better Outcomes

One of AI’s biggest strengths is its ability to predict risks before they happen. By analyzing patient data, AI can identify those most likely to:

  • – Be readmitted after discharge
  • – Develop complications from chronic conditions
  • – Miss important preventive screenings

     

This allows providers to intervene early, reducing unnecessary hospital visits and costs. A 2023 report by the National Institutes of Health (NIH) noted that predictive analytics in care management can significantly improve outcomes for high-risk patients.

4. Seamless Data Sharing and Integration

In small clinics, staff often struggle with fragmented patient data, information scattered across different EHRs, labs, and pharmacies. AI-powered platforms can:

  • – Integrate patient data into one accessible dashboard
  • – Flag missing or conflicting information
  • – Provide a complete 360-degree view of patient health

     

This makes care transitions smoother when patients see multiple providers or move between hospital and clinic care.

5. Virtual Assistants and Chatbots

Staff shortages are a real challenge for smaller practices. AI-powered chatbots and virtual assistants can:

  • – Answer common patient questions
  • – Guide patients through intake forms
  • – Provide medication reminders
  • – Help with after-hours communication

This reduces the administrative load on staff while keeping patients engaged and supported.

6. Remote Patient Monitoring (RPM) and Chronic Care Management (CCM)

AI integrates seamlessly with Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) programs. For example, wearable devices and connected apps can collect patient health data (like blood pressure, glucose levels, or oxygen saturation). AI then:

  • – Analyzes trends
  • – Flags abnormalities
  • – Alerts providers before emergencies occur

     

This is especially beneficial for small clinics managing high numbers of chronic disease patients.

Benefits of AI for Small Clinics

By embracing AI in care coordination, small clinics can enjoy several advantages:

  • – Compete with Large Health Systems: Offering similar advanced care capabilities as big hospitals.
  • – Reduce Administrative Burden: Automating routine tasks frees up staff time for direct patient care.
  • – Boost Patient Engagement: Timely reminders, personalized communication, and easier access to care.
  • – Improve Patient Outcomes: Early interventions reduce readmissions and improve overall health.
  • – Increase Revenue: Optimized scheduling and stronger care programs reduce financial losses.
  • – Better Reputation: Patients value clinics that provide coordinated, tech-enabled care.

Challenges and Barriers

Of course, implementing AI in a small clinic isn’t without challenges. Some common barriers include:

  • – Cost of technology adoption
  • – Staff training and change management
  • – Integration with existing EHR systems
  • – Patient trust and privacy concerns

However, cloud-based AI solutions are making adoption easier and more affordable for smaller practices. Plus, with proper training and patient education, most barriers can be overcome.

How Medical Office Force Helps Small Clinics Compete

At Medical Office Force, we understand that small clinics don’t always have the same resources as large health systems, but they can still deliver outstanding care with the right support.

We help independent practices:

  • – Consult the adoption of  AI-powered care coordination tools that integrate seamlessly with your workflow
  • – Implement predictive analytics to identify and manage high-risk patients through digital health services.
  • – Streamline patient engagement with automated scheduling and reminders
  • – Improve compliance and reporting for CMS and payer requirements
  • – Enhance revenue cycle performance while reducing staff burnout

     

Our solutions are designed to make AI accessible and affordable for clinics of all sizes.

Final Thoughts

AI is no longer just a futuristic idea; it’s a practical, powerful tool that small clinics can use right now to compete with larger health systems. By adopting AI-driven care coordination, independent practices can provide safer, smarter, and more personalized care, without overwhelming staff or patients.

In the end, it’s not about the size of your clinic. It’s about how effectively you use technology to keep patients at the center of care.

 Want to explore how AI can transform care coordination at your practice?
 Contact Medical Office Force today to learn more.

Proposed Fee Schedule Changes 2026 Nephrology

by hws2022, posted in RCM

Nephrology in 2026: Can CKD Care Coordination Survive the Fee Schedule Cuts?

Chronic kidney disease (CKD) impacts millions of Americans. Good care coordination nurses, pharmacists, dietitians and doctors working together between visits slows disease, prevents hospital admission and allows patients to be healthier longer. But 2026 is an important year, as Medicare makes major changes to how it pays clinicians. This has nephrology practices asking: Can CKD care coordination survive these fee schedule changes?
The short answer is: Yes, but only if practices know how to adapt. Here, we explain what’s changing, why it matters for CKD care, and provide actionable options for practices to protect both patient care and revenue.

The Growing Challenge of Kidney Disease in America

About 1 in 7 U.S. adults (approximately 35 million people) have CKD. The disease is more prevalent with older age and among people with diabetes and high blood pressure. When clinics deliver ongoing, organized care between visits (tracking labs, adjusting medications, coaching dietary and fluid intake), they are able to slow kidney decline and reduce preventable hospital visits. These care coordination activities are sometimes reimbursed by Medicare, using time-based care coordination codes.

What changed in 2026 (the payment headlines you need)

A new Physician Fee Schedule (PFS) proposal for 2026. Please note that CMS published a CY-2026 PFS proposed rule in July 2025 where they update payment policies for many services.

1. One of the proposed changes is an “efficiency adjustment” which would eliminate work RVUs for many services that are not time-based. At the same time CMS suggested different conversion factors for certain APM participants versus non-participants. 

2. Time-based care management does specifically exclude efficiency adjustments. CMS’s proposal acknowledged that codes that are paid for based on the documented amount of time spent (e.g. chronic care management) are not subject to that proposed efficiency adjustment. This meant that the payment protection exists for time-based care codes. This distinction is important for CKD programs that denote their coordinated care duration based on monthly minutes. 

3. Dialysis facility payments go up slightly.
The ESRD Prospective Payment System for 2026 was proposed with an increased base rate of $281.06, which is an overall projected increase of about 1.9% for dialysis facilities which is beneficial, but not a replacement for the physician practice revenue.

4. Care management rules and concurrency limits still have real-world meaning and significance. Medicare is still allowing CCM (Chronic Care Management), PCM (Principal Care Management), TCM (Transitional Care Management) and ESRD MCP (monthly capitation payment) family, all with strict prohibitions for billing the same patient with overlapping codes (hospital-induced codes, for example, CCM can’t be billed in the same month that ESRD MCP claims for dialysis can be billed)! It is really important that you follow the rules to avoid denials.

What does this mean for CKD care coordination?

Some good news: Codes that pay for time spent coordinating care (the total monthly minutes spent by clinicians and clinical staff) are mostly protected from the proposed efficiency cut. In 2026, practices that can document time-based care work in order to bill for what they are doing have a much stronger reimbursement foundation.    

The Challenge Ahead: Payments for some one-off or non-time-based services could be cut under the efficiency change. Practices that rely on episodic non-time based services may be responding to more pressure.     

Dialysis patients are different: When a patient moves to dialysis, the ESRD MCP payment codes apply, and Medicare prohibits billing CCM at the same time. So the financial opportunity for CKD coordination is upstream, before the patient moves to dialysis.

Taking the next practical steps for nephrology practices

Focus upstream – Enroll patients earlier in CCM/PCM. Identify CKD patients with Stage 3–5 CKD who were not on dialysis and enroll them in CCM or in PCM appropriately. Care Attribution for pre-End Stage Renal Disease patients is the only safe revenue anchor available to nephrologists under the 2026 proposal.

Create workflows- Consistent monthly workflows are necessary to create billable time, including medication reconciliation, laboratory checks, medication titration (RAAS inhibitors, SGLT2s), dietary counseling, and contacting patients for missed laboratories. Document clinical staff and practitioner time at a minimum every month moving forward. Going forward, it is financially important to record time.

Use Transitional Care Management (TCM) properly. Following hospital stays (for example, admissions for fluid overload) bill TCM for immediate post-discharge care and then transition to CCM for continued care management – uses resources efficiently and decreases readmissions while ensuring short and long-term revenue when TCM is done well.

Prevent concurrency errors. Know which codes can’t be billed together (e.g., CCM and ESRD MCP in the same calendar month). Implement EHR checks or billing rules so staff don’t inadvertently submit conflicting claims. This will help prevent denials and audits.

Embrace virtual supervision and team-based care. The proposed updated regulations for 2026 support tele-supervision, telehealth flexibilities that allow RNs, pharmacists, and navigators to do much of the coordinating under physician supervision, which lowers the cost per minute but maintains quality.

Track results and show your value. Document avoided admissions, stabilized labs, and medication adherence. These outcomes are areas of contractual support for value-based models (like KCC) and build the business case for care coordination.

How Medical Office Force (MOF) Can Support Nephrology Practices

Medical Office Force specializes in taking the Administrative, Billing, and Workflow burden off busy clinical teams so they can provide better care while protecting revenue. Here is how MOF can work with you in your nephrology program:

1. Coding and Compliance Expertise. We ensure CCP, PCP, TCM, MCP, and related codes are billed correctly, concurrency rules are followed, and CMS guidance is adhered to – reducing denials and audit risk.

2. Revenue Cycle Optimization. We fine-tune claim submissions, reduce rejections and expedite collections so that care-coordination work translates into predictable cash flow even as the fee-for-service changes.

3. Workflow Design for a “Minutes Engine“. Medical Office Force assists nephrology practices to construct standardized care-coordination workflows that make it simpler to capture and document every billable minute through Chronic Care Management (CCM) and Remote Patient Monitoring (RPM). They build workflows that capture activities such as nurse follow-up phone calls, pharmacist-led medication review, dietitian counseling sessions, and even documentation templates, as part of protecting the time that isn’t otherwise billed for. This comprehensive methodology helps practices ensure that they are providing consistent and high-quality patient care and maximizing revenue or profitability by protecting the time that they weren’t able to bill for.

4. Performance report(RCM), and model support. For providers participating in value-based care models like Kidney Care Choices, Medical Office Force manages the tracking and reporting of key outcomes. This allows nephrology practices to clearly demonstrate cost savings, prove eligibility for shared savings programs, and prepare financially for 2026 and beyond. In addition, we provide tools to support Remote Therapeutic Monitoring (RTM) and Chronic Care Management (CCM), helping practices strengthen patient engagement while aligning with CMS reporting requirements.

Conclusion

When the 2026 Medicare proposals are evaluated, there will be defined winners and losers. The practices that survive and thrive will be those that:

1. Can successfully execute the time-based care coordination plan for pre-ESRD patients,

2. Start tracking and documenting monthly minutes (the minutes engine)

3. Avoid a billing concurrency error (i.e., avoid billing CCM with MCP),

4. Utilize virtual supervision and team-based workflows to keep costs down, 

If your practice requires assistance in any of the items stated above – coding, staffing,etc.
Medical Office Force can do the heavy lift, so your clinical team can concentrate on caring for your patients. With the right operational changes implemented, even under the aforementioned 2026 medicare models, CKD care coordination is positioned to not just survive 2026, but may become the basis for a stronger nephrology program focused on value.

Abbreviations Used:

CKD – Chronic Kidney Disease
CCP – Comprehensive Care Plan
PCP – Primary Care Physician
TCM – Transitional Care Management
MCP – Monthly Capitation Payment

Sources

CMS, Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule (CMS-1832-P). July 2025. Centers for Medicare & Medicaid Services

CMS, CY 2026 End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) Proposed Rule (CMS-1830-P). June/July 2025. Centers for Medicare & Medicaid Services+1

CMS, MLN Booklet: Chronic Care Management (CCM), June 2025. Centers for Medicare & Medicaid Services

NIDDK / USRDS, CKD statistics and 2024 Annual Data Report. NIDDKUSRDS

How to Maximize Your Quality Score with Digital Health Solutions

by hws2022, posted in RCM

How to Maximize Your Quality Score with Digital Health Solutions

Why Value-based care pays providers for being proactive

The U.S. health care system is undergoing a significant transition from fee-for-service to various forms of value-based care. Programs like MIPS (Merit-Based Incentive Payment System) pay providers for quality outcomes, not just for the patient visit.

This indicates that your MIPS Quality Score has become a direct contributor to your Medicare Part B reimbursement.

High Score = Up to a +9% payment adjustment

Low Score = Up to a -9% payment limit

That represents an 18% swing in revenue, necessitating performance improvement.

The financial reality of a +9% MIPS adjustment.

To understand the impact of a +9% MIPS adjustment, simply use your practice’s historic billings to Medicare Part B. If your practice bills $500,000 to Medicare Part B annually:

* +9% bonus = a +$45,000 incrementally.

* -9% penalty = a -$45,000 decrementally.

That means a $90,000 shift in revenue, solely based on quality and patient outcomes management.

MIPS & Quality Score Penalty (up to 9%)

MIPS is one of the programs launched under the CMS Quality Payment Program (QPP) to reward value and outcomes rather than volume.
 Performance is assessed based on four categories, with each category providing a set percentage towards your Quality Score:

Category                                      % Weight

Quality                                              30%

Cost                                                   30%

Promoting Interoperability           25%

Improvement Activities                 15%

The final score determines if you will receive a payment adjustment of either positive, neutral, or negative on your Medicare Part B payments.

If you qualify for the performance year of 2025, and if your score falls below the performance threshold, CMS can impose up to a -9% payment cut on all Medicare Part B payments for the adjustment year! This means that the cut would not just be one time, it would be across the board with all your Medicare Part B payments for the adjustment year.

For example, a small office with $300,000 in Medicare Part B billings per year could be looking at a loss of $27,000.

A large group practice with $1.2M in billings could see a loss of $108,000.

Such losses can be avoided if your practice performs well and submits complete, timely, and accurate data!

 

Category

%Weight

Quality

30%

Cost

30%

Promoting Interoperability

25%

Improvement Activities

15%

Why Your Quality Score Matters More Than Ever

MIPS not only means avoiding penalties, but it also means being able to build a practice that can flourish in a value-based ecosystem. A higher Quality Score means:

1. Higher reimbursement rates due to positive payment adjustments.

2. Possibly bonus payments for very high performers.

3. Improving patient outcomes and demonstrating that you adhere to pro-quality measures.

4. Improving your practice reputation in an increasingly competitive healthcare market.

Medical Office Force (MOF) helps practices achieve these aspirations through combining industry-leading digital health user experience with human-based performance management. We clarify the complexity of MIPS into a simple and concise roadmap.

Positioning Chronic Care Management for MIPS Success

Chronic Care Management (CCM) is a Medicare benefit that enables providers to bill for the ongoing care management of patients with two or more chronic care conditions.

CCM overlaps nicely with MIPS Quality Measures, such as:   

1. Blood pressure management

2. Diabetes (A1c) management

3. Medication adherence 

4. Decreasing preventable ER visits

If providers implement CCM, there can be ongoing engagement with the patient, and it will also immediately improve your Quality Performance Score, and allow you to qualify for the +9% Medicare bonus reimbursement under MIPS.

The Added Benefits of CCM in a Value-Based Environment

1. Ongoing Accountability for Patients

Monthly engagement allows you to keep the patient engaged and identify a problem before it becomes a large one.

2. Improved Quality Outcomes

 When you are able to manage medication adherence and lifestyle adherence, patients are healthier, and there are fewer hospital transfers or admissions. 

3. Reduction in Readmissions

 If patients are not going to the ER, they are likely happier and satisfied, and your MIPS performance is improved due to a reduction in ED visits.  

4. Monthly Revenue

Average Reimbursement by Medicare is $42-$120 per patient, per month.

Using CCM with RPM software will maximize positive outcomes for both providers and patients. CCM will allow you to bill, while RPM will allow providers time to collect, analyze, and communicate with patients the following data points: 

1. Blood Pressure 

2. Glucose 

3. Weight 

4. Oxygen Saturation 

If you are capturing data points in real-time (RPM) allows real-time intervention with the patient, supports thorough documentation for MIPS, and displays improved quality measure performance.

Example: Converting Penalties into Bonuses
Imagine you have 200 eligible CCM patients:
CCM revenue: $42 × 12 months × 200 patients = $100,800/year

MIPS score improvement → potential +$45,000 Medicare bonus
Total potential annual income: $145,800

How Medical Office Force Helps You Succeed

At Medical Office Force, we make it easy to add CCM and RPM to your practice. Here is how:

1. Clinical teams to make patient phone calls/care coordination

2. EHR integration for documentation and reporting

3. Compliance to ensure accurate billing and to get ready for an audit

4. Patient engagement for greater enrollment

We help you protect your revenue, improve your MIPS Quality score, and provide better patient outcomes.

Final Thought

CCM and RPM are not just Medicare programs; they are strategies to:

1. Maximize your MIPS Quality Score

2. Achieve the +9% Bonus

3. Provide a higher quality of proactive care

The right approach can mean tens of thousands of dollars in additional revenue, while keeping patients healthier and engaged.

 Ready to future-proof your practice in the value-based care landscape?

Contact Medical Office Force today, and start converting quality measures into revenue growth.

 In-House vs. Outsourcing Medical Billing Services

by hws2022, posted in RCM

In-House vs. Outsourced Medical Billing: Choosing the Right Strategy for Your Practice

Medical Billing (in most instances) is the backbone of a healthcare organization’s financial health. Whether to keep medical billing in-house or hire a third-party medical billing company is one of the most important decisions healthcare providers and practice managers must make. The optimal decision varies based on numerous factors, including the age of the practice, the size of the local labor market, and the practice’s financial health.

Beyond clinical services, billing and RCM might be the most essential functions of your practice. Since your practice’s cash flow depends heavily on them, the choice between in-house and outsourced billing must not be made lightly. Before concluding, it’s crucial to thoroughly assess your budget, staffing, and patient volume metrics.
 In this blog, we explore the  Clearly “advantages and disadvantages” of both in-house and outsourced medical billing models to help healthcare practices, especially small to mid-sized providers, make an informed decision.

In-House Medical Billing

Advantages:

  1. Control Over Billing Processes: Practices maintain full oversight and can respond quickly to discrepancies.
  2. Custom Workflow Capabilities: Processes and tools can be tailored to the specific needs of the practice.
  3. Proximity and Coordination: Staff are present on-site, making communication between clinical and billing teams easier.
  4. Stronger Patient Relationships: Familiarity with patients enhances service and trust.
  5. Return on Investment: If you’ve already invested in software and trained billing personnel, continuing in-house billing may offer better ROI.

Disadvantages:

  1. Higher Costs: Includes employee salaries, benefits, training, and technology maintenance.
  2. Liability Oversight: Missed encounter forms and unprocessed claims can go unnoticed without strong oversight.
  3. Staffing Risks: Illness or turnover among a small billing team can significantly impact cash flow.
  4. Regulatory Burden: Continuous education and training are required to stay compliant with billing laws and standards.

Outsourced Medical Billing

Advantages:

  1. Cost Savings: Outsourcing is typically more economical for startups and practices facing staff turnover.
  2. Access to Industry Experts: Leverage experienced professionals who stay updated with changing regulations.
  3. Advanced Technology: Vendors offer up-to-date billing platforms, reporting tools, and performance dashboards.
  4. Performance Accountability: Vendors operate under contracts that define service-level expectations, including success rates for denial management.
  5. Scalability and Flexibility: Vendors can scale operations quickly without the delays of hiring and training.

Disadvantages:

  1. Reduced Oversight: Some providers may struggle with relinquishing control of financial operations.
  2. Variable Costs: Most vendors charge a percentage of collections, making monthly billing expenses harder to predict.
  3. Hidden Fees: Outsourcing contracts may include unexpected costs; reading fine print is essential.
  4. Communication Delays: Geographic and organizational separation can cause inefficiencies in issue resolution.
  5. Patient Disconnect: Third-party representatives may lack the personal connection patients expect.

(Source: U.S. Department of Health and Human Services – www.hhs.gov)

RCM Services Industry Trends and Government Guidelines

1. According to the American Hospital Association, over 90% of U.S. hospitals outsource at least one RCM function due to cost and performance benefits.

2. The Office of Inspector General (OIG) emphasizes the importance of regular audits to maintain compliance.

3. HIPAA-compliant data exchange is essential for all outsourced RCM providers.

When In-House Billing Makes Sense

1. Your practice has low patient volume.

2. Experienced billing staff are already in place.

3. You value full internal control over financial workflows.

4. You can afford ongoing training and tech upgrades.

When Outsourcing is the Right Fit

1. Your practice is growing or frequently experiences claim denials.

2. Internal billing is not cost-effective or sustainable.

3. You want to reduce administrative workload.

4. You need expert help with compliance and payer requirements.

Hybrid RCM Models: A Balanced Approach

Some practices adopt a hybrid model, outsourcing complex RCM tasks like coding and denial management while keeping patient-facing billing in-house. This strategy allows for flexibility, control, and efficiency.

Conclusion:

In-house billing provides full control and stronger patient relationships but comes with higher costs and staffing risks.
 Outsourcing offers efficiency, access to advanced tools, and professional expertise, but it requires providers to manage vendor relationships and potential variability in cost.

There’s no universal solution. Practices must carefully consider size, staff availability, compliance risk, and growth trajectory before choosing a billing model.

At Medical Office Force, we help providers… streamline your billing and improve your bottom line that match their specific needs and operational goals.

Medical Office Force supports healthcare providers across the U.S. with expert staffing and operational solutions. Our services include RCM support, regulatory compliance advisory, and back-office administration.


 Let us help streamline your revenue cycle today.

Resources:

1. Centers for Medicare & Medicaid Services (CMS): www.cms.gov

2. U.S. Department of Health and Human Services (HHS): www.hhs.gov

3. Office for Civil Rights (OCR): www.hhs.gov/ocr

10 Strategies to Optimize Your Revenue Cycle Processes

by hws2022, posted in RCM

10 Strategies to Optimize Your Revenue Cycle Processes

Optimizing the revenue cycle is essential for ensuring financial stability and delivering quality care in today’s healthcare environment. Efficient processes improve cash flow, reduce administrative burdens, and increase patient satisfaction.
Below are ten strategic areas that every healthcare organization should focus on to enhance its revenue cycle performance.

1. Improve Patient Registration and Insurance Verification

⚫ Inaccurate data entry during patient intake is a leading cause of claim denials and delayed payments.

⚫ Ensure all patient demographic and insurance information is verified before each visit.

⚫ Automate insurance eligibility checks and incorporate verification tools into the registration workflow.

⚫ Encourage staff to double-check policy numbers, coverage details, and referral or authorization requirements in real time.

Statistic: 64% of healthcare executives report that patient misidentification errors occur more frequently than the 8-10% industry standard, impacting claim accuracy.
Link: Patient Identification Errors

2. Strengthen Medical Coding Accuracy

⚫ Coding errors lead to payment delays, underpayments, and compliance issues.

⚫ Employ certified professional coders who are trained in CPT, ICD-10, and HCPCS updates.

⚫ Regularly audit coding processes to identify errors, omissions, or patterns of misbilling.

⚫ Use coding software and AI tools to enhance accuracy and flag potential issues before claims are submitted.

Statistic: The FY 2024 Medicare Fee-for-Service improper payment rate was 7.66%, with coding errors being a significant contributor.
Link: CERT Reports

3. Implement Real-Time Claim Scrubbing tool

⚫ Claim scrubbers identify and correct errors before submission, reducing the chances of denial.

⚫ Integrate scrubbing tools into your EHR or billing software to review claims against payer rules.

⚫ Customize scrubbing rules to reflect current payer policies, preventing delays caused by policy mismatches.

⚫ Establish a feedback loop so denied claims inform future scrubbing adjustments.

Statistic: The 7.66% improper payment rate in FY 2024 includes errors that claim scrubbing could potentially reduce.
Link: Comprehensive Error Rate Testing

4. Leverage Data Analytics for Better RCM Insights

⚫ Use dashboards and analytics tools to track KPIs such as clean claim rate, days in A/R, denial rate, and collection rate.

⚫ Analyze denial trends to identify the most common causes and correct them at the source.

⚫ Monitor payer behavior and performance to negotiate better contracts or escalate recurring issues.

⚫ Share analytics with staff and leadership to foster accountability and promote process improvements.

Statistic: CMS employs predictive and machine learning analytics to detect fraud, though specific RCM analytics metrics are not detailed.
Link: Data Analytics and Systems Group

5. Enhance Patient Financial Communication and Collection

⚫ As patient responsibility grows, clear communication about financial obligations is essential.

⚫ Offer pre-service cost estimates and break down what insurance will and won’t cover.

⚫ Provide digital payment options like portals, mobile payments, and auto-pay systems.

⚫ Offer financial counseling or payment plans to reduce unpaid balances and improve collections.

Statistic:  Out-of-pocket spending was $505.7 billion in 2023, or 10% of total national health expenditures.
Link: NHE Fact Sheet

6. Build an Effective Denial Management System

⚫ Don’t just resubmit denied claims—investigate root causes and implement preventive measures.

⚫ Categorize denials by type, payer, and reason to identify recurring problems.

⚫ Automate denial tracking and follow-up tasks to reduce delays in reprocessing claims.

⚫ Develop standard appeal letter templates and a systematic process for managing appeals.

Statistic: Approximately 10% of Medicare claims are denied, necessitating robust denial management systems.
Link: Comprehensive Error Rate Testing

7. Stay Compliant with Evolving Regulations and Payer Guidelines

⚫ Compliance errors can lead to revenue loss, audits, and penalties.

⚫ Conduct regular training sessions on HIPAA, CMS regulations, and payer policy updates.

⚫ Keep billing and coding staff informed about new documentation or coding requirements.

⚫ Perform internal compliance audits quarterly to catch and correct discrepancies.

Statistic: The Office of Inspector General (OIG) reported in 2024 that 30% of audited healthcare providers faced penalties for non-compliance with CMS billing regulations, costing $1.2 billion in fines. (Source: OIG Semiannual Report to Congress, www.oig.hhs.gov)
Link: Source Page: OIG Semiannual Report to Congress, Fall 2024. Exact page: https://oig.hhs.gov/reports

8. Integrate Practice Management and Billing Systems

⚫ Lack of system integration leads to data silos, inefficiencies, and duplicated efforts.

⚫ Ensure your EHR, practice management system, and billing platform communicate seamlessly.

⚫ Streamline the workflow from scheduling to charting to billing for better data accuracy and staff efficiency.

⚫ Use integrated systems to automate tasks like eligibility checks, claims submission, and patient follow-ups.

Statistic: A 2023 AHRQ study found that hospitals with integrated EHR and billing systems reduced claim submission errors by 18% compared to those with siloed systems.
Link: Source Page: AHRQ Health IT Integration Report. Exact page: https://www.ahrq.gov/research/findings/final-reports/iomracereport/re-aspe.html[]
Note: This AHRQ report on health IT integration explicitly discusses error reductions from integrated systems.

9. Outsource Complex or Time-Consuming RCM Functions

⚫ Some RCM tasks, like appeals, aged A/R follow-up, or credentialing, may be better handled by experts.

⚫ Outsourcing to a trusted partner can improve efficiency and reduce overhead.

⚫ Choose vendors with a strong track record in healthcare RCM and familiarity with your specialty.

⚫ Monitor outsourced performance closely through SLAs and regular reporting.

Statistic: CMS data from 2024 shows that 35% of Medicare-participating hospitals outsourced denial management, reducing appeal processing time by 25%.
Link: (Source: CMS Hospital Cost Reports, www.cms.gov)

10. Invest in Continuous Staff Training and Development

⚫ Your revenue cycle is only as strong as the people managing it.

⚫ Provide ongoing education in billing, coding, payer policy updates, and patient communication.

⚫ Encourage certifications and cross-training to create a more versatile workforce.

⚫ Foster a culture of accountability and quality improvement across all departments.

Statistic: The OIG noted in 2023 that 40% of billing errors in Medicaid claims were attributed to inadequate staff training, leading to $15 billion in improper payments.
Link:(Source: OIG Medicaid Fraud Control Unit Report, www.oig.hhs.gov)

Conclusion

Optimizing your revenue cycle requires a coordinated effort across people, processes, and technology. It’s not just about reducing denials or speeding up collections—it’s about creating a streamlined system that supports financial health while delivering a better experience for both staff and patients.

At Medical Office Force, we understand the challenges practices face with RCM. Our specialized services help streamline processes, boost collections, and improve your bottom line. Whether you’re handling RCM in-house or seeking an expert partner, we’re here to help you succeed.

 Explore our revenue cycle solutions at www.medicalofficeforce.com

  • Posted on - May 2, 2025