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Author: Lauren Brown

UnitedHealthcare’s September 2025

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UnitedHealthcare’s September 2025 bulletin announces the delayed implementation of a policy cutting reimbursements for off-campus provider-based departments, new routine lab testing policies with automated pre-payment reviews effective December 1, 2025, and updates to imaging, anesthesia, and procedure place‐of‐service reimbursement rules. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/rpub/UHC-COMM-RPUB-September-2025.pdf

AHIP Statement on Vaccine Coverage

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AHIP released the following statement on September 16, 2025, regarding vaccine coverage. “Health plans are committed to maintaining and ensuring affordable access to vaccines. Health plan coverage decisions for immunizations are grounded in each plan’s ongoing, rigorous review of scientific and clinical evidence, and continual evaluation of multiple sources of data. “Health plans will continue to cover all ACIP-recommended immunizations that were recommended as of September 1, 2025, including updated formulations of the COVID-19 and…
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CMS & CDC Updates: Lab Fee Schedule, Hepatitis C Screening, and Ebola Advisory

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Clinical Laboratory Fee Schedule: COVID-19 & Influenza Virus Types A and B Test Code For combination tests that are read visually, CPT code 87812 QW will take effect on January 1, 2026. Until then, laboratories may bill CPT code 87428 QW. Medicare Claims Processing Manual, Chapter 18 Update: Hepatitis C Virus Preventive & Screening Services Learn about hepatitis C virus updates (PDF) to the Medicare Claims Processing Manual, effective June 27, 2024:  From Our Federal Partners: Ebola Outbreak in the…
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2024 MIPS Targeted Review Now Open

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Clinicians and organizations can now review their 2024 MIPS final scores on the Quality Payment Program website (QPP) and, if needed, request a targeted review. A targeted review allows CMS to re-examine your score if you believe there’s an error—for example, incorrect TIN/NPI data, misapplied performance category reweighting, or if you qualify as a QP and shouldn’t receive a MIPS payment adjustment. The review window is open for about 60 days, beginning with the release of final scores…
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2024 MIPS Performance Feedback and Final Scores

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The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) performance feedback and final scores for the 2024 reporting year. How Do I Access Feedback? Need access? If you don’t have a HARP account or QPP role, follow the instructions in the QPP Access User Guide (ZIP, 4MB) to get started. Medicare Shared Savings Program Accountable Care Organizations (ACOs) Medicare Shared Savings Program ACOs should assign at least one individual as a…
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Cigna New Reimbursement Policy for Professional Evaluation and Management Services Claims effective October 1, 2025

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Cigna Healthcare will implement a new reimbursement policy, Evaluation and Management Coding Accuracy (R49), to review professional claims billed with Current Procedural Terminology (CPT) evaluation and management (E/M) codes for billing and coding accuracy in alignment with the American Medical Association (AMA) E/M services guidelines. Effective for dates of service on or after October 1, 2025, services may be adjusted by one level to reflect the appropriate reimbursement when the AMA guidelines are not met. What…
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2024 MIPS Scores, Cost Measure Exclusion, and 2025 APM Incentive Updates: Key Deadlines and Actions

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2024 MIPS Final Scores and Targeted Review Available Mid-September As previously announced (QPP listserv sent 7/25/2025), there was a delay with receiving some of the final Medicare claims data needed to calculate cost measures, which is delaying the release of MIPS final scores for the 2024 performance year and the Targeted Review period. MIPS payment adjustments for the 2026 MIPS payment year will be released approximately one month after the release of final scores. The…
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PPL Status Applies to Practices With CLIA Certification Higher Than CLIA Waived

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All Preferred Medical Doctors (PMD) and participating advanced practice providers are eligible for reimbursement of laboratory services identified in Exhibit I of the PMD Agreement. Providers who perform more advanced laboratory tests not listed in Exhibit I must be credentialed as a PPL to receive reimbursement. A new report is available that provides the status of the PPL designation for your providers. Access the “Preferred Physician Laboratory” report from Profiles & Reports by logging in to ProviderAccess. This report…
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Reminder: Preview Your CY 2023 QPP Data for Public Reporting + New Measure Release Notes Available

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The Centers for Medicare & Medicaid Services (CMS) has reopened the calendar year (CY) 2023 Doctors and Clinicians (DAC) Preview Period, which will remain open until Thursday, August 21, 2025, at 8 p.m. ET (5 p.m. PT). CMS reopened the Preview Period because adjustments were made resulting in the addition of 2 clinician quality measures and 17 group quality measures available for public reporting. CMS also made updates and display corrections to the CY 2023…
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New CMS Updates: Check Your 2025 APM Participation and QP Status Now

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CMS has released the first snapshot of 2025 APM (Alternative Payment Model) data through the Quality Payment Program (QPP) Participation Status Tool. This update includes Qualifying APM Participant (QP) status and MIPS APM participation status based on Medicare Part B claims from January 1 to March 31, 2025. If you’re participating in an APM, now’s the time to log into the QPP portal and check your status using your 10-digit NPI number. It’s essential to…
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