Revenue Cycle Management

Kim Hardin Urgent care organizations continue to face growing operational pressure as payer requirements become increasingly complex. Among the most significant challenges impacting revenue cycle performance today are provider onboarding and credentialing delays. In an environment where staffing shortages, payer consolidation, and administrative burden continue to rise, efficient credentialing has become critical to financial stability and patient access. Credentialing is the process of verifying a provider’s qualifications, licenses, education, training, malpractice history, and eligibility to participate with insurance payers. While this process has always been necessary, it has become far …
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Cindy Dickey; Tricia Krueger, CPC The Centers for Medicare & Medicaid Services (CMS) has introduced several important updates to therapy services for calendar year (CY) 2026. These changes affect reimbursement thresholds, telehealth services, coding practices, and payment reductions. Providers—including physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs)—should understand these updates to ensure compliance and optimize billing practices. One of the most notable updates is the adjustment of the KX modifier threshold. For CY 2026, the threshold amount has been set at $2,480. The KX modifier is used to …
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Kimberly Hardin, Josh Rainey As healthcare organizations look to modernize operations, the idea of a fully artificial intelligence (AI)-driven revenue cycle management (RCM) system is increasingly appealing in urgent care. Automating everything from coding and charge capture to claims submission and denial management promises efficiency, speed, and reduced labor costs. However, moving to a truly autonomous AI model introduces a range of risks that organizations must carefully evaluate before making the leap. Financial Exposure and Revenue Integrity One of the most immediate concerns with full AI RCM in urgent care …
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Samantha Etter, CPC; Reanna Nelson, CPC Healthcare reimbursement processes continue to evolve. In 2026, diagnosis-based denials have increased significantly across multiple payer types. Unlike procedural denials, diagnosis denials often stem from policy interpretation rather than incorrect coding. For urgent care, each denial impacts revenue cycle performance, increases administrative burden, delays reimbursement, and raises compliance concerns. Understanding the root causes behind diagnosis denials is essential for proactive prevention and long-term revenue integrity. Historically, diagnosis denials were primarily linked to medical necessity or unspecified codes. Recent payer shifts now focus on symptom-based …
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Tricia Krueger, CPC; Nikki Benedict Insurers are drawing provider backlash for new payment policies that reduce reimbursements. For example, Cigna is automatically “downcoding” 6 evaluation and management (E/M) billing codes for a small percentage of providers, resulting in lower payments for routine services like office visits. Aetna’s new Medicare Advantage policy will automatically approve certain hospital admissions but reimburse them at the lower observation rate instead of the full inpatient rate. Providers argue these opaque methods increase administrative costs and lead to underpayment. Implications for Urgent Care Centers The new …
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