Revenue Cycle Management

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC In the last few years, the Centers for Medicare & Medicaid Services (CMS) has accelerated its long-term effort to strengthen primary care as the foundation of the U.S. health system. Through new payment models, regulatory changes, and equity-driven initiatives, CMS aims to rebalance healthcare spending toward prevention, care coordination, and whole-person health. All these are areas historically underfunded compared to specialty or hospital care. Major policy changes have been enacted through the Physician Fee Schedule (PFS), including increased payment for longitudinal and continuous …
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Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC, is Revenue Integrity Manager at Experity. The financial and reputational health of an urgent care practice depends on one simple principle: Bill accurately and compliantly. Yet as reimbursement rules evolve and staffing models shift toward greater reliance on non-physician practitioners (NPPs), many centers find themselves at risk for costly missteps. From billing under the wrong provider to out-of-network (OON) complications and False Claims Act (FCA) violations, administrators are navigating an increasingly complex compliance landscape. Understanding how these issues intersect—and building proactive strategies to …
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Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC Revenue cycle management (RCM) may not be the most glamorous part of urgent care, but it is one of the most critical. A clinic can provide excellent patient care, yet still struggle to keep its doors open if its billing processes falter. Too often, urgent care leaders rely on assumptions, outdated practices, or incomplete data that lead to financial surprises and lost revenue. Running an effective Revenue Cycle Management program is like taking a photograph. When a camera is set to automatic mode, …
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Tricia Krueger, CPC, is RCM Coding Supervisor for Experity. ICD-10 has been ever changing since it was first adopted 10 years ago. Each year, the Centers for Medicare & Medicaid Services (CMS) revise, add, and delete diagnoses to better suit the conditions, including the conditions that present in urgent care centers. These changes reflect advances in clinical understanding and the need for more precise documentation in fast-paced care settings. While ICD-10 changes can happen semi-annually, most changes happen in October. For the upcoming 2025-2026 update, there are 487 new codes, …
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Nikki Benedict Timely filing is a critical concept in medical billing that directly impacts claim reimbursement. Despite its importance, the specific requirements and terminology can vary across payer contracts, making it essential for billing teams to understand both the general rules and the payer-specific nuances. When reviewing a payer contract, timely filing requirements may be outlined under the following sections: Submission/Adjudication of Claims Payment Time to File Claims Providers can find Medicare and Medicaid timely filing requirements by consulting Centers for Medicare & Medicaid Services (CMS) and relevant state Medicaid …
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