InSights 

Copays Only/No Deductibles? Yes.

United Healthcare (UHC) has a group plan called Surest. Perhaps unsurprisingly, it happens to be UHC’s best-selling plan. Surest features copays only, with no deductibles, coinsurance, or cost shifting.

Health Care Service Corporation (HCSC) has its own version of this with its "Simplified Health Care Coverage Option." If you're not familiar with HCSC, it is under the auspices of Blue Cross Blue Shield of IL, MT, NM, OK, and TX. Apparently, the "no deductibles/copays only" concept is catching on.

What do these insurance plans potentially mean for clinical laboratories and anatomic pathology groups? No doubt there’d be reduced patient A/R since responsibility balances for deductibles wouldn’t exist under those plans.

Click here for details from the HCSC press release.

(Regardless of your patients’ insurance coverage, ADSRCM empowers you to capture responsibility balances to the best extent possible with access to our patient responsibility estimator, with out-of-network alerts, with an automated prior authorizations option, with our team performing eligibility verifications up to four times prior to tests, and with a balance due reminder texting option.)

Ongoing Physician Payment Cuts may be the Unkindest Cuts of All

It was probably the next day or so after the Ides of March (aka, March 15) when Mark Antony eulogized Julius Caesar and pointed out one of Caesar’s particular wounds as being “the unkindest cut of all.” That was in 44 BC, or roughly 2,069 years ago to the day you’re probably reading this.

Now comes another unkind cut: the fifth year of Medicare payment cuts to physicians.

The American Medical Association (AMA) and many other organizations and societies are criticizing Congress for failing to stop the ongoing Medicare cuts.

The recap is that physicians faced a 2.83% payment cut to Medicare Physician Fee Schedule (MPFS) reimbursements on January 1. It happened, as mentioned, for the fifth time. The Medicare payment cuts also come as CMS estimates a 3.5% increase in the Medicare Economic Index (a guide measuring the cost of operating a medical practice).

In other words - or the same words - there’s a 2.83% reduction in Medicare reimbursements while the Medicare Economic Index shows a 3.5% increase in operating costs. You could say it’s an unkind cut.

Click here for an historical representation from the AMA of revenues vs. inflation, and here for a letter from the American College of Radiology as representing a consortium of over 100 other healthcare-related organizations.

Interesting Late-Breaking News from MedPAC

The Medicare Payment Advisory Commission (MedPAC) has just recommended that Congress align physician reimbursements more closely to inflation in 2026 by tying payment rates to the aforementioned Medicare Economic Index, minus one percentage point.

That is a step in the right direction. In fact, their idea would increase reimbursements throughout subsequent years, compared to payment increases in the past that were for one year only.

As expected, the AMA lauded MedPAC's advice to Congress and urged lawmakers to consider the commission's recommendations. If you're so inclined, you're encouraged to contact your representatives in DC as well.

Click here for the MedPAC report and here for the AMA press release.

(Irrespective of what may happen in 2026, right now and as you just read, reimbursements are down, but operating expenses are up. ADSRCM helps its clients maximize their reimbursements as optimally as possible while consolidating in-house staffing with our outsourced workforce.)

Information Blocking/Delayed Access to Medical Info = Penaltie$

Information Blocking/Delayed Access to Medical Info = Penaltie$

When patients or their authorized caregivers are blocked from access to their medical information or experience delays in that access, the 21st Century Cures Act can penalize the offending party (e.g., the practice, the hospital, and yes, the laboratory).

It’s why EHRs, for example, should be ONC-certified, which means they’re Cures Act compliant and, therefore, aren’t blocking information as described.

Penalties are happening. For example, HHS recently levied a $200,000 civil fine against an OR-based healthcare entity for “violating an individual’s right to timely access to her medical records.”

The complaint was made to the Office of Civil Rights (OCR), which oversees these matters. It was the second complaint against this same entity. In short, the OCR determined that the healthcare entity “failed to take timely action in response to the right of access requests.” In December 2024, the entity received notification of the $200,000 fine.

The lesson is crystal clear: the Cures Act is not to be taken lightly. It must be respected, or serious penalties could be levied. The potential consequences of information blocking are significant, and compliance with the Act is crucial.

Click here for the HHS press release on this incident.

Seeing Through Price Transparency

This one’s pretty self-explanatory: hospitals must make their fees easily accessible to patients, potential patients, and guarantors to help them determine costs for their own budgeting and financial planning.

Health plans will also need to make tools available with pricing information, negotiated rates with providers, out-of-network payments to providers, and the actual prices they or pharmacy benefit managers pay for prescription drugs.

CMS will be able to impose civil monetary penalties for failing to comply with transparency requirements, although as of this writing, only 18 have been levied with seven being under review.

Click here for an article from PatientsRightsAdvocate.org on price transparency, and here for the 18 entities that have been levied since June, 2022.

(Transparency is also important to you, which is why ADSRCM clients have transparent, on-demand access to all their data. Clients see exactly what we see at any time and are encouraged to do so to the extent they want.)

Medical Fraud Story of the Month

A NC-based doctor was sentenced to 30 months and ordered to pay over $2 million in restitution after pleading guilty to healthcare fraud and money laundering.

The doctor was the owner of a toxicology entity where he'd prescribe opioids and other controlled substances to patients regardless of medical necessity. The twist is that he'd routinely have patients provide urine for tests that were submitted for analysis by his toxicology business. These tests went on for almost three years, from 8/18 through 12/21.

Claims were submitted to Medicare and NC Medicaid for the highest possible reimbursements on urine drug tests (UDTs).

Click here for details from the IRS press release.

Onward Medicare Telehealthers!

You’ll be able to continue telehealth sessions for Medicare patients another six months through September 30; a termination date had been set for of March 31.

Click here for an informative article from the National Law Review.

(ADSRCM clients can access the ONC-certified MedicsCloud EHR and use the Medics Telemedicine app for virtual encounters with ADSRCM submitting those claims. Relatedly, clients can also access our remote patient monitoring app enabling them to monitor patients’ vitals and be paid for doing so!)