This month’s theme is transparency: insurers are rewriting where and how they’ll pay for the same service, and a new code set just took effect. Here’s what’s changing and why it works the way it does.
Current News
A major insurer just made “where you were treated” a billing question. Elevance Health announced on September 29 that it will require hospitals to report the physical location where care was delivered and pay off-campus services at off-campus rates — the first commercial payer to go public with this approach. The logic: a hospital-owned clinic across town has historically billed at hospital-outpatient rates, which run meaningfully higher than the same visit at a physician’s office. Elevance cites Blue Cross Blue Shield Association data showing Medicare and patients paid billions more over three years because of that gap. This is part of a broader “site-neutral payment” push already underway at CMS — worth understanding even if you don’t bill Elevance directly, since other insurers tend to follow once one sets a precedent.
Source: DistilINFO, reporting on Elevance Health’s announcement
Blue Cross Blue Shield of Michigan is phasing out “incident-to” billing. Incident-to billing lets a non-physician provider’s visit get reimbursed at the supervising physician’s higher rate. Starting this month, BCBS Michigan clinicians still billing this way must add modifier SA, and those claims lose eligibility for value-based incentive programs. A second phase in March 2027 cuts incident-to reimbursement to 80% of the fee schedule and removes eligibility entirely for trainees and residents. Practices that lean on non-physician providers have a two-year runway worth planning around now.
Source: DistilINFO, citing Michigan State Medical Society reporting
UnitedHealthcare tightened five lab-testing policies. New caps took effect in September: allergen testing limited to 20 allergens per year for patients 20 and older, hepatic fibrosis testing capped at once per six months, chemotherapy sensitivity assays no longer reimbursed, and B12 testing limited to once per quarter. Small print, real impact if your patient population leans on repeat lab work.
Source: DistilINFO
Billing and Coding Advice
FY2027 ICD-10-CM codes are now in effect. As of October 1, the new code set is live: 190 new codes, 30 deletions, and 4 revised titles, concentrated in injury/poisoning, pregnancy/childbirth, and musculoskeletal categories. If your EHR or clearinghouse update wasn’t confirmed before October 1, that’s the first thing to check — claims billed with deleted codes from this point forward risk rejection.
Source: Revenue Cycle Advisor
CPT 2027 is published — thirteen months of runway before it’s live. The AMA’s 2027 set, effective January 1, 2027, adds 299 codes, including 10 new AI-service codes and a full rebuild of the maternity-care billing bundle. The gap between publication and effective date exists specifically so practices can map and test before billing — OB/GYN practices especially have real work to do before year-end.
Source: American Medical Association
Aetna is financially penalizing outdated radiology equipment. Aetna now applies a 15% payment cut to radiology billed with modifier CT — the modifier for equipment that doesn’t meet the NEMA “Smart Dose” standard for radiation-dose optimization. It’s a direct financial nudge to upgrade older imaging hardware, aligned with a CMS policy already in place. Worth knowing even if you don’t bill Aetna, since this is the kind of standard other payers tend to adopt once one sets the precedent.
Source: DistilINFO
Patient and Insurance Reimbursement Advice
The proposed 2027 Medicare fee cut is still just proposed. The public comment period closed September 14 with over 44,000 responses filed. The final rule — including the proposed conversion factor cut and the 50%-same-day-billing change — is expected around November 1. Nothing changes yet, but modeling the impact against your top billed codes now means you’re not starting from zero when it finalizes.
Source: Holland & Knight
Payer prior-authorization APIs are due January 1, 2027. Under CMS-0057-F, Medicare Advantage, Medicaid, CHIP, and exchange plans must stand up FHIR-based prior-authorization APIs by that date. In plain terms: faster, more standardized prior-authorization decisions are coming. The deadline sits with payers, not practices — there’s nothing to build on your end, just a process that should get less painful.
Source: CMS
Blue Cross Blue Shield of North Carolina changed how multi-procedure claims get paid. For claims with multiple procedures in one visit, the primary procedure now pays at 100%, the second at 50%, and the third-and-beyond at either 25% (professional) or $0 (facility). This is a standard “multiple procedure reduction” structure — even outside North Carolina, it’s a useful model for understanding how payers generally price same-visit bundling.
Source: DistilINFO
Where to Start
None of this has to be handled alone. If you want a clearer picture of where your own practice stands on denials, collections, and coding accuracy, start here:
And if you’d rather just talk it through, we offer a free 30-minute Practice Analysis where we look at your actual numbers together — no obligation, no cost.