06/17/2025

Recent RAC Monitor Article

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AI’s Rise in Diagnostic Medicine: A New Frontier
Artificial intelligence (AI) is rapidly reshaping diagnostic medicine. From radiology and dermatology to primary care and mental health, AI systems – particularly those powered by large language models (LLMs) and advanced image recognition algorithms – are enhancing diagnostic accuracy, reducing costs, and redefining physician roles.

Diagnostic Capabilities: Matching or Exceeding Clinicians
There have been a number of meta-analysis studies that compared the diagnostic accuracy of generative AI against physicians in settings ranging from primary care to specialized fields. The pooled accuracy of these AI models was statistically similar to that of non‑expert physicians, though expert physicians still outperformed AI by nearly 16 percent, according to a study by UVA Health. Notably, some AI models – such as GPT‑4, Gemini 1.0 Pro, and Claude 3 – showed comparable accuracy to non‑experts, according to the Journal Nature.com.

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Leveraging the QIO for Patient-Level Appeals Under MA Final Rule 4208
The finalized Medicare Advantage (MA) Rule 4208 includes important clarifications of enrollees’ rights to appeal denied inpatient stays. In my casual reading for clarification on another topic, which will be discussed in a future article, I noticed this statement on page 175:

“We note that similar policies exist for other types of coverage denials. For example, after an MA organization determines that covered inpatient care is no longer necessary, the enrollee may file an expedited appeal of the discharge decision to the QIO (Quality Improvement Organization). If the QIO upholds the MA organization’s decision, and the enrollee has left the hospital, in accordance with § 422.622(g)(2), the enrollee may continue their appeal to the ALJ (administrative law judge), Departmental Appeals Board (DAB), and ultimately, Federal court (if other conditions are met).”

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Why Price Transparency is a Rare Unifying Issue
Price transparency in healthcare has long been a stated priority for the Trump Administration, both the first and second, and several recent public moves have demonstrated this commitment. 

Recently appointed Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz delivered remarks about his vision, and first up on his list of priorities was implementing President Trump’s executive order (EO) on transparency.

This executive order on price transparency was essentially a reissue and update to an EO on the subject Trump issued during his first term. In this most recent order, he said his Administration would issue new rules and guidance before June that ensure that pricing data is standardized and comparable across health systems and insurers, and that hospitals post actual prices of services, as opposed to estimates. 

However, several states are taking the matter into their own hands, as we’ve frequently seen them do on several recent healthcare issues.

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Audio-Only Telehealth: Coding Risks and Documentation Must-Haves

The State of Audio-Only Telehealth
Audio-only telehealth was first broadly permitted under emergency COVID-19 public health flexibilities in 2020. Since then, Congress and the Centers for Medicare & Medicaid Services (CMS) have extended its allowance under select conditions through the Consolidated Appropriations Act.

In 2025, Medicare continues to reimburse audio-only services in specific scenarios, including behavioral health, primary care, and established patient visits. However, coverage and compliance vary drastically by payor, state, and clinical context, making documentation and coding precision more critical than ever.

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CMS Crackdown on Medicaid Coverage for Undocumented Patients Raises Red Flags for Hospitals, Case Managers, State Programs
In a significant policy shift with wide-ranging implications for healthcare operations, the Centers for Medicare & Medicaid Services (CMS) announced that it will ramp up enforcement actions against states that use federal Medicaid dollars to provide healthcare to undocumented immigrants. This initiative, tied to a broader executive order focused on ending “taxpayer subsidization of open borders,” signals a more aggressive posture from the federal government and threatens to reshape how hospitals care for vulnerable patient populations.

While federal law has long restricted Medicaid funding to cover only emergency medical services for noncitizens without legal immigration status, CMS contends that states have stretched those definitions – often in the interest of delivering humane, cost-effective care. But under this new directive, such flexibility may soon come at a cost.

“Medicaid is not, and cannot be, a backdoor pathway to subsidize open borders,” said CMS Administrator Dr. Mehmet Oz in a press release. “We are putting states on notice – CMS will not allow federal dollars to be diverted to cover those who are not lawfully eligible.”

What’s Changing: Increased Oversight and Financial Consequences
As part of its enhanced oversight, CMS will begin focused audits of state Medicaid spending (CMS-64 reports), conduct in-depth reviews of financial systems, and assess eligibility rules to identify improper payments. The goal is to recoup federal matching funds from states that are out of compliance. CMS is also calling on states to urgently update internal controls, eligibility systems, and cost allocation policies.

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Compliance as a Revenue Strategy
Grab your pens, alert your billing teams, and cue up your electronic medical record (EMR) vendors, because the Centers for Medicare & Medicaid Services (CMS) just dropped game-changing updates for 2025, and this time, it’s not just about staying compliant – it’s about unlocking real revenue. These changes are for Medicare Part B payments.

Let’s start with vaccines.

Hepatitis B vaccines and their administration will now be reimbursed at 100 percent of reasonable cost. That puts them on the same playing field as influenza, pneumococcal, and COVID-19 vaccines.

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