Heads up: this issue is from May 22, 2025. Because it covers time-sensitive coding and regulatory topics, some details may have changed since. See the latest issues for current guidance.
The Senate Judiciary Committee discussed PBM Reform as they do frequently, with no result. The hearing examined the role of PBMs and how current practices impact drug pricing, access to medication, and local pharmacies. Republican and Democratic senators expressed concerns over low reimbursement rates to local pharmacies, lack of transparency, and the impact of vertical integration on drug affordability. Several witnesses emphasized the need to reform PBMs and recommended that future policies prioritize patients over profit.
Diagnostics companies are struggling to escape the shadow cast by Theranos, the blood-testing biotech that failed in spectacular fashion. That challenge is already facing the new diagnostics startup Haemanthus — and it hasn’t even emerged from stealth. Of course, it doesn’t help that Haemanthus is led by the partner of disgraced Theranos founder Elizabeth Holmes, who is serving 11 years in a federal prison for defrauding investors. Haemanthus CEO Billy Evans, who has two children with Holmes (who were conveniently born during her trial), is in fundraising mode for the startup, according to reports this week from NPR and The New York Times, which cited marketing materials and anonymous sources.
UnitedHealth Group plans to discontinue paying commissions to brokers and sales agents who sell new Medicare Part D prescription drug plans starting next month. The insurer, which has had a rough week that included a new CEO and reports of a federal criminal investigation, on Thursday notified companies that market its plans of the change. Justin Brock, CEO of Bobby Brock Insurance, an insurance agency in Tupelo, Mississippi, was among those who received a phone call from UnitedHealthcare on Thursday, notifying him of the decision, and was informed that a formal notification would follow. UnitedHealthcare did not say why it was making the change and will continue to pay commissions on renewals, Brock said.
Part B News warns that you should make sure your staff know when they can count the independent review of a test toward medical decision-making (MDM) in E/M coding. Independent interpretation of a test can lift the level of the “amount and/or complexity of data to be reviewed and analyzed (data)” element of an E/M visit to moderate or extensive, depending on the work performed for an encounter. During the CPT & RVBRVS 2024 Symposium, a pre-submitted question inquired whether a physician or qualified healthcare professional (QHP) can count both the order and the interpretation of a test on the same day in their office, provided the interpretation is completed before a radiologist creates the official interpretation. The AMA officials who oversaw the creation of the new E/M guidelines answered “yes” and repeated the guideline, which states that “a test that is ordered and independently interpreted may count both as a test ordered and interpreted.”
A coalition of seven remote monitoring companies announced Wednesday (May 14) the formation of the Remote Monitoring Leadership Council to advocate for policies that would expand patient access to remote patient monitoring (RPM), such as increasing geographic practice cost indices for Medicare RPM codes and establishing new codes. The council argues that broader access to high-quality RPM services would support HHS Secretary Robert F. Kennedy Jr.’s Make America Healthy Again (MAHA or, as I like to refer to it, HAHA) agenda. During a Wednesday press conference, members of the Remote Monitoring Leadership Council expressed support for the Rural Patient Monitoring Access Act, which Sens. Marsha Blackburn (R-TN) and Mark Warner (D-VA) recently introduced. The bill would increase reimbursements for Medicare’s five RPM codes by increasing practice expense and malpractice geographic practice cost indices (GPCIs) to 1.00 if the indices are less than 1.00. The bill would allow CMS to increase Medicare RPM reimbursement rates in a non-budget-neutral manner.
UnitedHealth Group has agreed to pay nearly $1.8 million to resolve a class action lawsuit brought against its subsidiary Optum, alleging the company used illegal robocalls to push home healthcare services, including prescription delivery (!!!!) and telemedicine. A lawsuit claimed the company used artificial, prerecorded voice messages sent by robo dialers to advertise Optum at Home, even to people who were not signed up to receive calls, regardless of whether or not those on the receiving end opted out. This constituted a violation of the Telephone Consumer Protection Act (TCPA), plaintiffs alleged. Although UnitedHealth agreed to the settlement, the company does not admit to any wrongdoing in making the calls, which reportedly occurred between Dec. 11, 2019, and March 27, 2025.
The rich just get richer. BioSpace recently did a deep dive into executive pay, examining the highest compensation packages, pay ratios, and golden parachutes—what a CEO would get paid to leave. Among our findings, Eli Lilly’s David Ricks was mentioned many times. He handily beat Johnson & Johnson’s Joaquin Duato for the top slot on our list of the highest compensated pharma execs. Duato, who topped the list in 2023, took in $24.6 million last year, nearly $5 million less than Ricks.
The American Hospital Association recommends that the Health and Human Services Department eliminate or ease a slew of regulations on billing, quality reporting, the workforce, and other areas in a letter sent to regulators. President Donald Trump has made deregulation a centerpiece of his expansive overhaul of the federal government, including at HHS. The AHA wrote the department Monday, offering more than 100 suggestions for policies to scrap in response to an April solicitation from the White House Office of Management and Budget, which also generated responses from other healthcare interests.
Want to credit Prescription Drug Management in E/M visits? E/M maven, Betsy Nicoletti, suggests: For a coder to credit prescription drug management, the practitioner must first assess and manage the condition for which a medication is prescribed. The CPT® definition is “Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.” The second part is ordering the prescription medication for the condition. Join Coding Intel for more great info like this.
CMS has released Draft Guidance for the third round of drug negotiations. Because Trump hates everything Biden, this may never happen. The draft guidance includes new policies to incorporate drugs payable under Part B into the Negotiation Program for the first time. It solicits comments on how to facilitate access to any negotiated Medicare Part B Formularies (MFPs) for drugs payable under Part B. Additionally, the draft guidance outlines how CMS would choose, for renegotiation, certain drugs that were negotiated for initial price applicability in years 2026 or 2027. The draft guidance also includes clarifications regarding how participating manufacturers would make any negotiated MFPs available in 2026 and 2027 and extends such policies for drugs covered under Part D to 2028. Of course, this all may be moot if MFN is adopted.
