Heads up: this issue is from December 16, 2025. Because it covers time-sensitive coding and regulatory topics, some details may have changed since. See the latest issues for current guidance.
Well, the new year is almost upon us!!! To help you during this super-busy time of year, I have a little checklist for you to make sure you haven't forgotten anything before you start imbibing holiday cheer.
And here it is:
- Verify all patient insurance for those in treatment. This year, it is particularly poignant, as many patients on the Exchange (Obamacare) may drop their plans or stop paying premiums in the next year. Also, Medicare patients may be going on or off Medicare Advantage.
- Get authorizations for each plan and/or patient where authorization must be renewed annually or (God forbid) quarterly.
- Pre-authorize all drugs, therapies (i.e., Radiation), and other services/procedures with new codes (e.g., RPM, RTM). Make sure insurance covers new codes and services in the new year, or when they are covered in 2026.
- Update your facility for the new codes you will use in 2026 in your EMR, Patient Accounting System, and pharmacy inventory.
- Update your charge entry for the new RVUs, allowables, and charges. Check these against your commercial fee schedules and Medicare spreadsheets.
- Update patient estimate algorithms and/or documents for correct codes, charges, and out-of-pocket costs for 2026. Medicare's 2026 numbers are right here.
- Interview patients regarding Obamacare increases and whether they will stay on their plan. Right now, there is no help for patients who have had it before. Is there another source of reimbursement for these patients? Is there a charity that can help?
- Prepare for more patients becoming self-pay and/or going to Patient Assistance for drugs. Kaiser Family Foundation estimates that 1 in 4 patients on Obamacare may go without insurance if there are no subsidies. What is your strategy for those patients?
- Run your numbers with all new contracted rates, 'non-time-based codes', and possible increased bad debt from uninsured or lapsed insured patients. While Medicare allowables are supposed to grow, there are cuts for some codes, specialties, and facilities.
- Participate in the struggle. While we all like to pay less tax, some cuts will come at the expense of your patients. Lobby to ensure your patients get the help they need.
Again, if you are a pharma company or distribution channel, patient access depends upon your being prepared for some of this as well!!!
