Vital Signs: A February 2025 wrap-up of revenue cycle management healthcare news

Welcome to “Vital Signs,” your go-to monthly roundup of all things related to RCM tailored for independent practices and medical billers. Access previous editions for the top insights and developments here.

There has been no shortage of revenue cycle management (RCM) healthcare news stories the last month. In this article, we highlight some of the most relevant topics, including Medicare Advantage prior authorizations, artificial intelligence (AI) to reduce administrative burden, telehealth coding, and more. Here’s a roundup of 9 newsworthy stories to share with others in your medical practice or billing company.  

The specifics: Non-group qualified health plans (QHP) purchased directly through Healthcare.gov deny, on average, 20% of in-network claims, according to a recent analysis from KFF. 

Why it matters: The KFF analysis comes against the backdrop of growing enrollment in all ACA Marketplace plans. Experts say insurance claim denials harm patients’ health and finances. 

What’s next: Pursue proactive strategies to mitigate denials with a focus on administrative errors, staff education, and tools and technology.

The specifics: Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023, according to a recent analysis. 

Why it matters: This analysis reflects steady year-over-year increases since 2021 as the number of people enrolled in Medicare Advantage has grown.

What’s next: When prior authorization denials occur, appeal them. Though a small share of prior authorization denials were appealed to Medicare Advantage insurers, most appeals (81.7%) were partially or fully overturned in 2023, the analysis found.

The specifics: The majority (86%) of physicians agree physician associates (PAs) expand access to care, and 90% say PAs are important to enhancing care delivery, according to a recent survey. 

In addition, more than half (55%) of physicians say removing barriers to PA practice would reduce patient wait times, and 68% of those who support modernizing PA laws believe doing so would help ease provider shortages.

Why it matters: Americans recently ranked improving healthcare access and affordability as their top public health priority. 

What’s next: Familiarize yourself with the education and training required to become a PA and brainstorm ways in which your medical practice may be able to leverage PAs more effectively to improve access and generate more revenue.

The specifics: Experts say the Trump Administration’s tariff plans could have a negative impact on the healthcare supply chain, particularly related to prescription drugs and drug components made outside of the United States, specifically in Canada and China.

Why it matters: Tariffs that affect the supply chain could affect medical practice financial stability and the ability for providers to adhere to best practice standards of care.

What’s next: Prepare for supply chain disruptions and higher healthcare costs. This includes promoting vendor diversification for medications and materials. In addition, consider purchasing supplies in bulk and stay abreast of economic policy changes.

The specifics: Medical practices and other Health Insurance Portability and Accountability Act (HIPAA)-regulated entities with 2024 data breaches affecting fewer than 500 individuals must submit a report to the Office for Civil Rights (OCR) by March 1, 2025 to avoid a financial penalty. 

Why it matters: Financial penalties associated with noncompliance may be significant depending on the level of negligence, extent of harm caused by the breach, and other factors.

What’s next: If your medical practice experienced a breach, it’s important to act quickly. Data breach reports must be submitted via the OCR data breach portal, with each data breach submitted separately. 

In addition, strive to protect the security of patient data moving forward. Healthcare was the most breached sector in 2024, according to a recent report. Healthcare is also the top industry impacted by data breaches specifically caused by a third party, a recent report found.

The specifics: Sixty-seven percent of surveyed primary care physicians (PCPs) agree or strongly agree that GLP-1 prescriptions for weight loss through a third-party telehealth provider may put their patient’s health at risk, a recent survey found. The survey defines third-party telehealth prescribers as those who prescribe GLP/GIPs for weight loss to patients who may be under the care of a different traditional primary care physician who is not otherwise part of their practice, and is distinct from specialists in their system’s network. 

PCPs' top 3 concerns associated with telehealth prescribers of GLP-1 meds? Overprescribing, lack of care continuity, and lack of complete medical history.

Why it matters: The number of telehealth providers writing GLP-1 prescriptions continues to increase. So does the number of patients who seek these medications. 

What’s next: Experts say PCPs play a critical role in prescribing GLP-1 medications given their relationship with patients, understanding of medical histories, and ability to address side effects and provide lifestyle support. 

They’re also adept at motivational interviewing that can help patients sustain weight loss over time. As a side note, doctors can leverage patient interest in GLP-1 medications to improve care quality and boost practice revenue.

The specifics: Sixty-six percent of physicians used healthcare AI in 2024, up from 38% who said they used it in 2023, according to a recent survey from the American Medical Association (AMA). More than half of physicians — 57% — said reducing administrative burdens through automation was the biggest area of opportunity for AI. 

Why it matters: This rapid increase reveals a growing optimism about AI’s potential in healthcare despite persistent concerns about oversight, integration, and liability. 

What’s next: Start exploring the potential of AI to improve patient care and operational efficiency in your practice. According to the AMA survey, the most common physician uses of AI include:  

Here’s a link to a survey that describes specifically how PCPs are using AI and the anticipated 3-year impact of AI on primary care delivery.

Also be sure to read up on AMA’s work to support the development of high quality, clinically-validated AI deployed in a responsible, ethical, and transparent manner. 

The specifics: While the telehealth coding landscape remains complex, the American Academy of Family Physicians (AAFP) did recently provide some guidance to help medical practices sort through the confusion. This article from the American Academy of Professional Coders (AAPC) is also helpful.

Why it matters: Incorrect telehealth coding can lead to costly payment delays and denials.

What’s next: Do your best to stay abreast of regulatory changes, including new telemedicine codes for 2025 as well as pandemic-era telehealth flexibilities currently set to expire on March 31, 2025.

The specifics: While a federal judge dismissed 5 out of 7 counts in a class action lawsuit against UnitedHealth Group, he allowed the 2 remaining counts to move forward — 1 for breach of contract and 1 for breach of the implied covenant of good faith and fair dealing.

Why it matters: This lawsuit is part of a larger trend calling attention to payers’ use of AI algorithms to deny claims. 

What’s next: Stay tuned for additional news related to the outcome of this case. Note that in February 2024, CMS issued guidance clarifying that while algorithms can assist in predicting patient needs, they cannot solely dictate coverage decisions. 

More recently, Texas lawmakers introduced a bill that would prohibit insurers from using AI to delay, deny, or modify claims, giving the state the authority to audit insurers for compliance. In addition, a new California law went into effect January 1, 2025 that prohibits payers from making coverage decisions based solely on AI algorithms.