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Medicare and billing

1,038 articles · Since 2004

Physicians writing on KevinMD about Medicare payment, the relative value unit system that sets it, coverage and authorization rules, and what the program pays for time and thinking against procedures. Three maintained records draw on this archive: Primary care: what physicians say, in their own words, Prior authorization: what physicians say, in their own words, and Direct primary care: what physicians say, in their own words.

Latest articles

Health policy

Medicare Advantage profits are speeding the collapse

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I receive emails from a senior citizen's organization urging me to sign a petition to protect Medicare Advantage (MA) nonmedical benefits. After reading and deleting the first one, I ignored subsequent ones for two reasons. First, since CMS, the federal…

I receive emails from a senior citizen’s organization urging me to sign a petition to protect Medicare Advantage (MA) nonmedical benefits. After reading and deleting the first one, I ignored subsequent ones for two reasons.

First, since CMS, the federal agency that administers Medicare, allowed private insurers to provide these benefits, their cost grew by over 800 percent. CMS intended these benefits to improve elder health, but this was not codified, …

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Medicare Advantage profits are speeding the collapse

Health policy

Surgery center profit margins were highest at nonprofits

A research letter published in JAMA Health Forum on September 25, 2026, examined the 2024 financial reports of 257 ambulatory surgery centers (ASCs) in Pennsylvania. The finding was not what the usual debate over outpatient medicine would lead you to…

A research letter published in JAMA Health Forum on September 25, 2026, examined the 2024 financial reports of 257 ambulatory surgery centers (ASCs) in Pennsylvania. The finding was not what the usual debate over outpatient medicine would lead you to expect.

Nonprofit centers represented 20.6 percent of the facilities. They collected 35.8 percent of the revenue and earned 51.5 percent of the net income. Their median profit margin was 37.8 percent. …

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Surgery center profit margins were highest at nonprofits

Physician voices

Moral agency in medicine is being squeezed by payer audits

Health care these days has encountered a genuine Catch-22 with a spiral downward effect: Declining real reimbursement rates push practices to increase patient volume to maintain revenue; higher volume compresses time for thorough documentation; and inadequate or incomplete documentation then…

Health care these days has encountered a genuine Catch-22 with a spiral downward effect: Declining real reimbursement rates push practices to increase patient volume to maintain revenue; higher volume compresses time for thorough documentation; and inadequate or incomplete documentation then triggers payer audits, denials, and clawbacks (recoupments) of already-paid claims, which feeds into declining reimbursement. Multiple sources discussed below, from Medicare data, physician surveys, CMS actuarial analyses, industry reports, …

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Moral agency in medicine is being squeezed by payer audits

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Physician finance

Physicians paid for G2211 twice. Most never bill it.

In 2024, Medicare cut every physician's rates about 2 percent to fund a code that 3 out of 4 of them never billed. The cut was automatic. The code has to be claimed by hand. The code is G2211. CMS…

In 2024, Medicare cut every physician’s rates about 2 percent to fund a code that 3 out of 4 of them never billed. The cut was automatic. The code has to be claimed by hand.

The code is G2211. CMS calls it a visit complexity add-on. In plain words, it pays for office visits where you are the patient’s ongoing doctor, either as the continuing focal point for all their care …

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Physicians paid for G2211 twice. Most never bill it.

Conditions and diseases

Medicare home care coverage pays for rehab, not an aide

American medicine has a peculiar definition of generosity. We will spend enormous sums treating a seriously ill older person: an ambulance, an emergency-room visit, scans, intravenous medications, surgery, and days in hospital. We may then pay to send a profoundly…

American medicine has a peculiar definition of generosity. We will spend enormous sums treating a seriously ill older person: an ambulance, an emergency-room visit, scans, intravenous medications, surgery, and days in hospital. We may then pay to send a profoundly frail patient to a skilled-nursing facility for “rehabilitation.”

But suppose what that patient really needs is someone to help her out of bed, make breakfast, and keep her safe at home. …

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Medicare home care coverage pays for rehab, not an aide

Physician voices

Cognitive assessment in primary care almost never happens

In my primary care practice, few moments carry as much quiet weight as when an older patient leans in and says, "Doctor, I'm worried about my memory." That moment is increasingly common, given that an estimated 42 percent of adults…

In my primary care practice, few moments carry as much quiet weight as when an older patient leans in and says, “Doctor, I’m worried about my memory.” That moment is increasingly common, given that an estimated 42 percent of adults who reach age 55 will develop dementia in their lifetime, so nearly every family will face a version of it. It takes courage to say those words out loud, …

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Cognitive assessment in primary care almost never happens

Health policy

How to reduce prescription abandonment at the counter

This month, the Centers for Medicare & Medicaid Services (CMS) took an important patient-centered step by proposing rules requiring faster, more transparent prior-authorization decisions for prescription drugs. Regulators are finally signaling recognition of a truth pharmacists have known for years:…

This month, the Centers for Medicare & Medicaid Services (CMS) took an important patient-centered step by proposing rules requiring faster, more transparent prior-authorization decisions for prescription drugs. Regulators are finally signaling recognition of a truth pharmacists have known for years: Information patients need to fill a prescription often arrives too late to matter.

That truth applies well beyond prior authorization. Across the prescription ecosystem, pricing, coverage, and authorization data routinely …

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How to reduce prescription abandonment at the counter

Health policy

How to fix health care without Medicare for All [PODCAST]

Medicare for All keeps dying in Congress. So what would actually get the major players to agree on universal coverage? Health care journalist Ken Terry returns to lay out a different model, one that keeps insurance companies in the system…

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Medicare for All keeps dying in Congress. So what would actually get the major players to agree on universal coverage? Health care journalist Ken Terry returns to lay out a different model, one that keeps insurance companies in the system while putting primary care doctors back in charge of basic care. …

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How to fix health care without Medicare for All [PODCAST]

The Podcast by KevinMD

How Medicare’s new cut is closing private doctor practices [PODCAST]

A 30 to 40 percent Medicare cut just hit the doctors who keep your local hospital running, and the policy meant to stop hospital monopolies is accelerating them instead. John Birkmeyer, president of the medical group at Sound Physicians and…

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A 30 to 40 percent Medicare cut just hit the doctors who keep your local hospital running, and the policy meant to stop hospital monopolies is accelerating them instead. John Birkmeyer, president of the medical group at Sound Physicians and a former Dartmouth health services researcher, discusses the KevinMD article “Medicare practice expense cuts will hurt patients.” You’ll hear …

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How Medicare’s new cut is closing private doctor practices [PODCAST]

The Podcast by KevinMD

How Medicare is breaking nursing home care [PODCAST]

Imagine being penalized for delivering good care to your frailest patients. Medicare's quality scoring program was built for healthy outpatients, not the elderly residents of nursing homes, but it is the system doctors who round in skilled nursing facilities are…

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Imagine being penalized for delivering good care to your frailest patients. Medicare’s quality scoring program was built for healthy outpatients, not the elderly residents of nursing homes, but it is the system doctors who round in skilled nursing facilities are forced to play. Steve Buslovich, a physician executive and geriatrician, discusses the KevinMD article “How Medicare’s MIPS impacts skilled …

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How Medicare is breaking nursing home care [PODCAST]

The Podcast by KevinMD

20 years inside a Medicare Advantage insurer, and who actually pays [PODCAST]

Medicare Advantage covers more than half of seniors, and the debate over what it really costs is stuck in two camps. Timothy Bulat, a senior consulting actuary who spent nearly two decades leading Medicare Advantage analytics inside a major insurer,…

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Medicare Advantage covers more than half of seniors, and the debate over what it really costs is stuck in two camps. Timothy Bulat, a senior consulting actuary who spent nearly two decades leading Medicare Advantage analytics inside a major insurer, raises a question the loudest voices keep avoiding: who actually pays for the program, and is the value being shared …

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20 years inside a Medicare Advantage insurer, and who actually pays [PODCAST]

Conditions and diseases

Medicare will pay for the work your nurses already do

Walk into any independent primary care practice and ask the nurse what she did on her lunch break. There's a good chance she'll tell you she was on the phone with the daughter of a dementia patient, calling the dialysis…

Walk into any independent primary care practice and ask the nurse what she did on her lunch break. There’s a good chance she’ll tell you she was on the phone with the daughter of a dementia patient, calling the dialysis center to sort out a transportation problem, or following up on the discharge med rec for the COPD patient who landed in the ED again last week. None of it …

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Medicare will pay for the work your nurses already do

Health policy

Medicare physician pay has fallen 33 percent since 2001

Patient care is getting squeezed. For years now, the Medicare Physician Fee Schedule has failed to give doctors the resources they need to keep up with rising costs and deliver high-quality care. The result is real strain on practices, especially…

Patient care is getting squeezed. For years now, the Medicare Physician Fee Schedule has failed to give doctors the resources they need to keep up with rising costs and deliver high-quality care. The result is real strain on practices, especially smaller and independent ones, and growing risks for patients who rely on Medicare.

When you adjust for inflation, Medicare payment rates to physicians have dropped by about 33 percent …

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Medicare physician pay has fallen 33 percent since 2001

Physician finance

How Medicare changes affect medical billing contracts

Policy changes eventually become operating decisions Most coverage of Medicare payment changes stops at reimbursement. A practice reads that a rule changes payment for certain services, then asks the obvious question: How much revenue is at risk? That question matters,…

Policy changes eventually become operating decisions

Most coverage of Medicare payment changes stops at reimbursement. A practice reads that a rule changes payment for certain services, then asks the obvious question: How much revenue is at risk?

That question matters, but it is not the only operator question. Medicare practice expense and related Physician Fee Schedule changes also affect the billing-service decision. If the practice outsources billing, the policy change does not …

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How Medicare changes affect medical billing contracts

Conditions and diseases

Patients pay when Medicare care coordination codes go unused

In my years as an ICU nurse, I learned to recognize a pattern. The patients I cared for in trauma surgical intensive care often arrived after a cascade of preventable events. A missed medication. A symptom that went unaddressed. A…

In my years as an ICU nurse, I learned to recognize a pattern. The patients I cared for in trauma surgical intensive care often arrived after a cascade of preventable events. A missed medication. A symptom that went unaddressed. A follow-up appointment that never happened. By the time they reached my unit, the question was no longer how to keep them well at home. It was how to bring them …

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Patients pay when Medicare care coordination codes go unused

Health policy

Medicare practice expense cuts will hurt patients

Recent federal cuts to how Medicare pays physicians are likely to deliver significant negative consequences to independent medical practices. The Centers for Medicare and Medicaid Services' (CMS) final rule for the 2026 Medicare Physician Fee Schedule imposes a dramatic reduction…

Recent federal cuts to how Medicare pays physicians are likely to deliver significant negative consequences to independent medical practices.

The Centers for Medicare and Medicaid Services’ (CMS) final rule for the 2026 Medicare Physician Fee Schedule imposes a dramatic reduction in payment rates for medical services performed in hospital settings by independent clinicians.

The payment reduction fails to account for the true resource costs incurred by independent physician practices, creating an …

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Medicare practice expense cuts will hurt patients

Health policy

Medicare payment is failing rural health

Ten years ago, I quit my job and started a solo office-based practice in rural Washington. I serve patients like Mr. G, an elderly gentleman who drove over 70 miles through mountain passes and rural highways to receive care for…

Ten years ago, I quit my job and started a solo office-based practice in rural Washington. I serve patients like Mr. G, an elderly gentleman who drove over 70 miles through mountain passes and rural highways to receive care for gangrene of his foot, as nearby hospitals were either too full or too far away. But Medicare’s broken payment system is endangering practices like mine, quietly dismantling access to affordable …

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Medicare payment is failing rural health

Health policy

Congress must make telemedicine permanent now

On October 1, unless Congress acts, millions of Americans will lose access to telemedicine. A proven tool that has kept patients safe, doctors present, and costs down will vanish not because it failed, but because lawmakers failed to make it…

On October 1, unless Congress acts, millions of Americans will lose access to telemedicine. A proven tool that has kept patients safe, doctors present, and costs down will vanish not because it failed, but because lawmakers failed to make it permanent. That would not just be bad policy. It would be malpractice by Congress.

I think of a patient of mine in northeast Georgia who lives 90 minutes from my clinic. …

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Congress must make telemedicine permanent now

The Podcast by KevinMD

How the Medicare Prescription Payment Plan transforms health care [PODCAST]

Brian Whorley, a health care executive, dives into the groundbreaking Medicare Prescription Payment Plan (MPPP), exploring its potential to revolutionize medication adherence and patient outcomes. With 54 million beneficiaries eligible, this initiative promises to alleviate cost barriers, reduce hospital readmissions,…

Listen on Apple Podcasts · Spotify

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

Brian Whorley, a health care executive, dives into the groundbreaking Medicare Prescription Payment Plan (MPPP), exploring its potential to revolutionize medication adherence and patient outcomes. With 54 million beneficiaries eligible, this initiative promises to alleviate cost barriers, reduce hospital readmissions, and save billions annually. Join the conversation to learn how providers …

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How the Medicare Prescription Payment Plan transforms health care [PODCAST]

Health policy

Medicare’s decision to stop telehealth coverage in 2025: an urgent call to action

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Medicare is planning to stop coverage for telehealth in 2025—unless Congress acts by the end of 2024. According to Medicare's website: Absent Congressional action, beginning January 1, 2025, the statutory limitations that were in place for Medicare telehealth services prior…

Medicare is planning to stop coverage for telehealth in 2025—unless Congress acts by the end of 2024.

According to Medicare’s website:

Absent Congressional action, beginning January 1, 2025, the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 PHE will retake effect for most telehealth services.

This means most telehealth visits will not be covered by Medicare in 2025, unless Congress acts by the end of December 2024.

Congress …

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Medicare’s decision to stop telehealth coverage in 2025: an urgent call to action

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