KLA Healthcare Consultants

08/06/2026

This is a great reminder!

08/05/2026

YOUR EMR SCHEDULE IS MORE THAN A CALENDAR

When an EMR is installed, its scheduling template often arrives with neat little 15-minute appointment blocks. The provider’s office adds providers, blocks out starting and quitting times, lunch, and little more.

But here is the reality: patients do not arrive in neat little 15-minute packages.

Leaving the default unchanged is a little like wearing a one-size-fits-all hospital gown and non-slip socks: usually possible, but seldom a good fit.

Just as you would rather not squeeze size 14 sasquatch feet into socks that are too small, a thoughtful template recognizes that different visits require different amounts of time, personnel, rooms, and equipment.

A new patient may arrive with years of medical history, several medications, records from multiple specialists, and concerns that were not fully described when the appointment was made.

An Annual Wellness Visit usually requires a Health Risk Assessment, medication reconciliation, cognitive evaluation, fall-risk assessment, depression screening, substance-use screening, personalized health advice, and a preventive-care plan.

A follow-up visit with a long-established patient may require a few lab tests, a brief check-in about medication effectiveness, and a pleasurable "catch up" with the patient.

YOUR SCHEDULE AS AN AUDIT BUSTER

CMS does not impose a universal 40-minute minimum for every Annual Wellness Visit.

However, CMS originally valued the initial AWV, G0438, by crosswalking it to a higher-level new-patient visit. For scheduling purposes, the initial AWV should be treated as approximately a 45-minute service, with a shorter benchmark of about 30 minutes for subsequent annual visits.

That is not a stopwatch rule—but it should make us pause before squeezing an Annual Wellness Visit into a routine 15-minute slot.

Contract auditors increasingly use claims analytics, comparative utilization, service volumes, and time metrics to identify providers whose billing patterns substantially exceed those of their peers.
CMS directs Medicare contractors to analyze claims for billing aberrancies. Comparative Billing Reports specifically compare providers with others in the same state and across the nation.

Some reports calculate measures such as average allowed minutes per visit.

AUDITORS ARE WATCHING YOUR CLOCK EVEN IF YOU ARE NOT

If the services billed suggest that a provider regularly accomplishes more work in a day than the available hours reasonably permit, the pattern can lead to record requests, prepayment review, post-payment review, or broader investigation.

The schedule alone does not prove—or disprove—that a service was properly performed. But once a provider is selected for review, the auditor may ask:
• Who performed each component?
• Was that person properly trained, licensed, or credentialed?
• Was the service within that individual’s scope of practice?
• Was the required level of supervision present?
• Does the documentation identify and support the work performed?

One serious problem exposed by time-and-volume analysis is the use of unqualified or insufficiently supervised personnel to perform work that Medicare rules reserve for appropriately trained professionals.

“Someone in the office did it” is not a reassuring answer during an audit.

DESIGN THE SCHEDULE AROUND THE ENTIRE WORKFLOW

An effective scheduling template should consider much more than the provider’s face-to-face time:
🩺 Will the patient need laboratory testing before or after the visit?
🩻 Will an X-ray require a technician, room availability, interpretation, and another conversation with the patient?
🧠 Will qualified ancillary personnel assist with depression, anxiety, cognitive, substance-use, or social-needs screening?
📋 Does the staff need additional time for medical records, medication reconciliation, questionnaires, or preventive-care gaps?
🚑 Is there protected space for a truly urgent established patient or unexpected overflow?

Without coordination, the laboratory can have a line down the hallway while the provider sits in an exam room with no patient to see. Everyone may be working hard—just not in the same place at the same time.

THE PROVIDER MAY BE CAPTAIN, BUT EVERY HAND MATTERS

And every hand should be involved in establishing your scheduling template. We have even seen schedules where Rooms vs. Providers were scheduled.

The provider remains the captain of the ship, responsible for clinical judgment, appropriate delegation, and oversight. But no ship moves safely because the captain runs from deck to deck trying to pull every rope.

Medical assistants, nurses, technicians, laboratory personnel, care managers, front-desk staff, and billing professionals each contribute to safe, efficient patient care. Every hand has a defined role. Every hand must be appropriately trained. And every hand should be valued.

“All hands on deck” does not mean all hands are interchangeable (even though we at KLA emphasize cross-training). A well-designed schedule coordinates those hands. It includes longer new-patient and wellness appointments, designated procedure and diagnostic blocks, appropriately scheduled ancillary personnel, same-day urgent appointments, and intentional buffers.

Buffers are not wasted time. They absorb late arrivals, unexpected complexity, emergency calls, additional counseling, and the thousand of small surprises that make medical offices medical offices.

Your EMR schedule should reflect how care is actually delivered—not merely how the software arrived from the factory.

Schedule the work—not just the clock.

If you have any scheduling suggestions, please share below.

04/07/2026

🚨 2027 CPT Changes Are Coming… and This Is Not Your Usual “Annual Update” 🚨

This is one of those moments when healthcare leaders may want to put down the coffee ☕, pick up the red pen ✍️, and start planning now.

Most of the buzz has centered on OB care—and for good reason 👶

The American Medical Association is previewing a major CPT restructuring for maternity services in 2027, moving away from global maternity packages toward an itemized approach.

Translation:
“Bundle it all together” may be becoming… “let’s document what actually happened.” 📋

And yes—this is a BIG shift.

But OB is only one part of the story…

🧠 AI & Digital Health Expansion
New Category III codes continue to emerge for:

AI-assisted diagnostics
3D modeling
Advanced imaging analytics

👉 Reminder: “The computer suggested it” is still not a billable service 😅. Real provider interaction is still needed to bill! But that AI can sure help expand thinking.

🩻 Radiology & Specialty Proposals
New and revised codes are being proposed across specialties, including:

Imaging procedures
Biopsy techniques
Advanced diagnostics

If your practice touches imaging at all… now is the time to pay attention 👀

💰 CMS Medicare Advantage Changes (2027)
The Centers for Medicare & Medicaid Services is tightening things up:

🚫 Excluding “unlinked” chart review diagnoses from risk scoring
📊 Updating risk adjustment models
⚖️ Applying a 5.90% coding pattern adjustment

👉 Translation: documentation accuracy just became even more important.

🤔 Why All These Changes?

Across the board, the goal is:

✔️ More accurate reimbursement
✔️ Better alignment with real-world care
✔️ Keeping up with modern medicine (including AI)
✔️ Reducing over- or mis-reporting

In short…
Healthcare is moving from “what was typical” → to “what actually happened.”

📣 Want to Support or Comment on CPT Changes?

Here’s where you can get involved:

👉 AMA CPT Editorial Panel (Interested Party Process):
https://www.ama-assn.org/practice-management/cpt/cpt-editorial-panel-meeting-interested-party

You can:

Submit comments 💬
Review proposals 📄
Participate in meetings (yes, really!)

Because sometimes the best compliance strategy is… showing up early.

📅 Bottom Line for Practices

2027 is shaping up to be a structural change year, not just a code update.

Now is the time to:

Review service lines
Educate providers
Tighten documentation
Watch proposal timelines closely

Because “we’ll figure it out in January” is not a compliance plan 😄

At KLA Healthcare, we’re tracking these changes so you don’t have to panic later.

(We prefer calm, organized preparation… with coffee. Lots of coffee.) ☕😉

02/13/2026

📋 When Was the Last Time You Looked at Your Forms?

Healthcare laws evolve.
Regulations shift.
But forms? They often sit quietly… unchanged for years.

One of the most overlooked compliance risks in a medical practice is an outdated Notice of Privacy Practices (NPP).

With updated federal regulations governing substance use disorder (SUD) treatment records under 42 C.F.R. Part 2, effective February 16, 2026, now is the time to take a careful look at your privacy language.

Not because anyone did something wrong.
Because the law changed.

🧠 Why This Law Exists

42 C.F.R. Part 2 was created in the 1970s to protect individuals seeking treatment for substance use disorders. At the time, stigma was severe — people feared job loss, arrest, or discrimination if their treatment became known.

So the federal government created stronger confidentiality protections than HIPAA.

Fast forward to modern healthcare: integrated care, shared electronic records, coordinated treatment teams.

The CARES Act began aligning Part 2 more closely with HIPAA. The final harmonizing rule takes effect February 16, 2026.

Now:

• Patients may sign a single written consent allowing use and disclosure for treatment, payment, and healthcare operations (TPO).
• Once disclosed pursuant to that consent, records may be redisclosed consistent with HIPAA.
• Anti-discrimination protections are strengthened.
• Civil and criminal penalties apply for improper use.

The purpose is better care coordination — while still protecting patient privacy.

🔎 What This Update Does — and Does NOT Do

✔️ It updates confidentiality rules regarding the sharing of SUD treatment information when proper written consent is obtained.

❌ It does NOT change prescribing laws.
❌ It does NOT reduce documentation requirements.
❌ It does NOT eliminate monitoring safeguards for controlled substances.

This rule addresses privacy and information sharing, not compliance with prescription regulations.

📑 Documentation Still Required

Practices prescribing controlled substances (including MAT medications, opioids, stimulants, benzodiazepines, etc.) must still maintain appropriate safeguards such as:

• Signed controlled substance agreements
• Documentation of checking the state Prescription Drug Monitoring Program (PDMP)
• Documentation of PDMP queries prior to prescribing
• Urine drug screening agreements and documentation of results
• Pill counts when clinically appropriate
• Treatment plans and ongoing risk assessments
• Documentation of medical necessity
• Informed consent for risks, side effects, and alternatives
• Tapering or discontinuation plans when indicated

Privacy compliance and prescribing compliance are two separate lanes. Both matter.

✍️ Language to Add to Your Existing NPP

For practices that do not want to rewrite their entire Notice of Privacy Practices, this paragraph may be inserted under your “Uses and Disclosures” section.

Because this is new regulatory language, it should be included in bold type within your NPP to clearly inform patients of the updated protections and permissions.

Special Confidentiality Protections for Substance Use Disorder Records:
Certain records relating to substance use disorder diagnosis, treatment, or referral may be protected under federal law (42 C.F.R. Part 2). Effective February 16, 2026, federal regulations permit the use and disclosure of such records for treatment, payment, and healthcare operations with a single written patient consent. Redisclosure of these records is permitted in accordance with HIPAA unless otherwise restricted by law. Unauthorized disclosure may subject the disclosing party to civil and criminal penalties under federal law.

🛠 Practical Takeaway

This is a good moment to:

• Review your Notice of Privacy Practices
• Update Part 2 language
• Confirm your redisclosure warnings
• Review your consent forms
• Ensure prescribing documentation protocols remain strong

Compliance is maintenance, not panic.

If you’re unsure whether your forms reflect the 2026 changes, now is the time to look — not after an audit.

01/21/2026

Medicare MIPS Reporting in 2025: Why It Matters (and What to Do If Your EMR Can’t Submit) 🩺📊

If you participate in Medicare and MIPS reporting is part of your world, here’s the not-so-small detail many practices overlook:

If MIPS requirements are NOT met, Medicare reimbursement can be reduced by up to 9% on Part B payments. 😬 If MIPS IS met (or exceeded), clinicians may avoid penalties and earn positive payment adjustments.

That 9% might sound theoretical… until it isn’t.

For large systems, a MIPS penalty can sting.

For small and solo practices, it can hurt a lot more. 💸

Smaller practices often operate on thinner margins, have fewer administrative staff, and don’t always have an EMR that automatically submits data to Medicare. That doesn’t mean MIPS doesn’t apply — it just means the pathway looks different.

CMS allows clinicians to submit MIPS data through approved third-party platforms when an EMR can’t do it directly. 🙌

Below are CMS-approved options commonly used by practices, with a quick sense of cost and complexity:

MDinteractive
A long-standing CMS Qualified Registry
Approximate cost: $389–$499 per clinician per year depending on categories submitted
Good for practices wanting straightforward submission with strong support
Website: mdinteractive.com

Mingle Health (MIPS Solutions)
Registry with dashboards, scoring tools, and hands-on guidance
Approximate cost: about $49 per provider per month (billed annually)
Good for practices that want year-round tracking and coaching
Website: minglehealth.com/products-services/mips-solutions

PRIME Registry
Qualified Clinical Data Registry (QCDR)
Approximate cost: $460–$515 per clinician per year
Good for small to mid-size practices wanting a clean, simple reporting dashboard
Website: primeregistry.org/reporting

Patient360
Registry and QCDR with advanced analytics and specialty measures
Cost varies (custom quote required)
Good for practices with more complex data or specialty needs
Website: patient360.com

Why this matters especially for small practices 👇
Smaller groups often feel the MIPS pinch more sharply because:
• A 9% cut hits a smaller revenue base harder
• There’s less room for billing errors or missed deadlines
• Administrative time = real lost patient care time

The right reporting platform can mean the difference between:
“Why is Medicare paying us less this year?” 😵‍💫
and
“Glad we handled that proactively.” 😌

KLA Healthcare helps practices:
• Understand MIPS requirements in plain English
• Evaluate which reporting platform fits their size and workflow
• Coordinate billing, compliance, and reporting so nothing falls through the cracks

Because doctors should spend more time with patients — not wrestling spreadsheets at midnight. ☕📋

If your EMR doesn’t submit MIPS data directly, that doesn’t mean you’re stuck — it just means you need the right path forward.

Questions? We’re happy to help you think it through.

01/21/2026

Healthcare is changing—not because clinicians care less, but because the system now asks them to be healers, documentarians, coders, compliance officers, data-entry specialists, and occasionally mind-readers… all before lunch 😅📋.

At KLA Healthcare, we work closely with clinician offices every day, and we see the pressure firsthand. Most clinicians want nothing more than to think deeply, listen carefully, and partner meaningfully with their patients. Instead, many are juggling prior authorizations, EHR alerts, quality metrics, audits, billing rules, and regulatory requirements—often while being expected by payors to see four to six patients an hour ⏱️.

It’s a lot. And that’s putting it mildly.

This reality calls for smarter workflows, not harder ones—and maybe a little grace for everyone involved.

One of the most promising shifts we’re seeing is the thoughtful use of modern tools—such as AIs including ChatGPT and Grok—to help patients come to visits better prepared, more informed, and more engaged in their own care 🤝.

When clinicians encourage patients to advocate for themselves using structured preparation tools, something powerful happens.

A prepared patient helps the clinician focus faster. A concise written summary allows the clinician to quickly scan key information, confirm accuracy, and apply their expertise where it matters most 🧠. Instead of spending valuable minutes reconstructing medication histories from memory or decoding “that little white pill,” clinicians can engage in higher-level decision-making and patient education.

This is not about replacing clinical judgment. It’s about enhancing the visit—and preserving a little sanity along the way.

A prepared patient helps the clinician focus faster. A concise written summary allows the clinician to scan key information quickly, confirm accuracy, and apply their expertise where it matters most 🧠. Instead of spending valuable minutes reconstructing medication histories from memory or decoding “that little white pill,” clinicians can engage in higher-level decision-making and patient education.

This approach also aligns with good compliance and risk management practices ⚖️. Encouraging patients to understand their medications, risks, and benefits supports informed consent and shared decision-making—both increasingly emphasized by regulators, accrediting bodies, and payors.

Clinicians may already know that certain medications carry risks or interactions and have determined that a particular regimen represents the best risk-benefit balance for a patient. When patients come prepared with thoughtful questions, it opens the door to calm, transparent conversations rather than rushed explanations. Education builds trust. Trust improves adherence. Adherence improves outcomes 🌱.

From a practice-management standpoint, engaged patients can also reduce downstream friction—fewer follow-up calls, fewer portal messages that begin with “Sorry to bother you…,” and clearer documentation of patient understanding 📉.

At KLA Healthcare, we encourage clinician offices to see patient advocacy tools as allies, not adversaries. Teaching patients how to prepare responsibly for visits—through written checklists, structured summaries, or AI-assisted organization—supports efficiency, quality care, and sustainability in a system that is asking clinicians to do more than ever.

Our suggestion: prepare a one-page patient handout that supports your patients in using AI to compile their symptoms, questions, medications, etc. for each visit. It will help them and you for the most meaningful visit.

Modern healthcare works best when clinicians are supported, patients are informed, and systems are designed for collaboration rather than burnout ❤️.

That’s where thoughtful leadership—and smart infrastructure—make all the difference.

01/19/2026

Today we honor the legacy of Dr. Martin Luther King Jr.—a leader who reminded the world that dignity, fairness, and respect are not abstract ideals, but daily practices.

Dr. King believed that systems matter. He understood that when systems are unjust, overwhelmed, or poorly designed, people suffer—even when individuals within those systems are doing their best. That insight still resonates today, including in healthcare.

At KLA Healthcare, we see Dr. King’s legacy reflected in the quiet, often unseen work of building systems that support people rather than exhaust them. Clear rules. Fair processes. Ethical leadership. Respect for those doing the work and those being served.

Honoring Dr. King means continuing to ask hard questions with humility, improving systems with integrity, and remembering that behind every policy, regulation, and workflow is a human being deserving of dignity.

May we lead with clarity, compassion, and courage—especially when the work is complex and the stakes are high 🕊️.

01/15/2026

Prior Authorization Comes to Traditional Medicare And Why Providers Are Seeing It Everywhere 👀📋

For decades, Traditional (Fee-for-Service) Medicare was considered the calm harbor of healthcare reimbursement — fewer hoops, fewer forms, and far less prior authorization than its commercial and Medicare Advantage cousins.

That era is officially ending.

Beginning in 2026, CMS will roll out a prior authorization pilot program in six states, introducing utilization management requirements into traditional Medicare for the first time at scaleat scale While the pilot is geographically limited, its ripple effects are already being felt nationwide — including in Medicare Advantage plans and commercial insurance, even outside the pilot states.

If it feels like prior authorization is multiplying faster than rabbits in springtime… you’re not imagining it. 🐇📄

Why Is This Happening? (The Legislative Backstory)

The Push to Reduce “Waste, Fraud, and Abuse” 💸

CMS has long cited concerns that a meaningful portion of healthcare spending goes toward services that may be unnecessary, duplicative, or low-value. Historically, Medicare addressed this through post-payment audits and enforcement actions.

The new approach?
Move the review before the service, notidentified by CMS after.

Enter the WISeR Model (Wasteful and Inappropriate Service Reduction). This pilot allows CMS to test whether prior authorization can reduce questionable utilization without harming patient outcomes.

In theory, it’s about better stewardship of taxpayer dollars.
In practice, it means… more paperwork. 📑😅

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What the Medicare Pilot Actually Does

Starting January 1, 2026, providers in six states will need prior authorization for a defined list of services that CMS has identified as having a higher risk of inappropriate use.

A few key points worth emphasizing:

Coverage rules do not change
Appeal rights remain intact
Reviews are conducted by licensed clinicians (with technology assisting, not replacing them)
Providers may choose between pre-service authorization or post-service medical review

CMS frames this as a “measured test.” Providers often experience it as a “measured test of patience.” 😬

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Why This Isn’t Staying in Just Six States

Even though the Medicare pilot is limited geographically, many providers are already seeing similar requirements appear elsewhere — particularly in:

Medicare Advantage plans
Commercial insurance products
Employer-sponsored plans

Why?

Because payors talk to each other, watch CMS closely, and often adopt utilization management strategies before they become universal policy. If CMS is testing prior authorization in traditional Medicare, private insurers are unlikely to sit on the sidelines.

Think of it as a policy “soft launch.” 🚀

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Medicare Advantage & Commercial Plans: Already Old Pros at Prior Auth

Medicare Advantage plans have relied heavily on prior authorization for years. Commercial carriers, likewise, have long required authorization for everything from imaging to injections to durable medical equipment.

Recently, insurers have acknowledged what providers already know:

Prior authorization
Delays care
Increases administrative burden
Contributes to staff burnout

As a result, many carriers have publicly committed to modernization efforts, including:

Expanded electronic prior authorization
Faster turnaround times
Fewer services requiring approval
Clearer clinical criteria

That’s the good news.

The less good news? Implementation varies widely by carrier, plan type, and region. 🧩

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What We’re Seeing from Carriers (In the Real World)

While policies differ, common themes are emerging:

Requirements may apply even outside CMS pilot states
Some plans require authorization “just in case”
Product-specific rules matter (HMO ≠ PPO ≠ MA ≠ Commercial)
Older policies sometimes linger long after updates are announced

Translation: Assumptions are risky. Verification is essential. ✔️

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Practical Guidance for Providers & Practice Managers

Here’s what we recommend in this evolving environment:

1. Don’t assume Medicare = no prior auth anymore
Always confirm — especially for high-cost or frequently reviewed services.

2. Check the plan, not just the carrier
Requirements often differ by product line.

3. Use payer portals and electronic tools whenever possible
They’re not perfect, but they’re usually faster than faxing into the void. 📠➡️🕳️

4. Document medical necessity clearly and early
Clear notes save time on the back end.

5. Talk directly with payor representatives
When requirements are unclear, ask:

Does this service require prior authorization?
What documentation is required?
What are turnaround times?
Are there any upcoming policy changes?

Getting confirmation before the service can prevent denials, rework, and uncomfortable patient conversations later.

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The Bottom Line 🧭

Prior authorization is no longer just a Medicare Advantage or commercial insurance issue. It’s becoming a system-wide utilization management strategy, and providers should expect continued expansion — even beyond formal pilot programs.

The practices that navigate this best will be those that:

Stay informed
Build strong payor relationships
Invest in efficient front-end processes
And verify, verify, verify 🧐

At KLA Healthcare, we help practices stay compliant, reduce administrative friction, and adapt confidently as the reimbursement landscape continues to shift.

01/07/2026

A little glimpse of our LinkedIn leadership series. Hope you enjoy.

The Mississippi River does not try to do everything. It carries commerce, history, memory, and momentum across half a continent — steady, enduring, unapologetic.

01/05/2026

Top 10 Billing Truths Every Private Practice Physician Should Know for 2026

Billing in 2026 is less about “learning new tricks” and more about knowing which rulebook applies. Here are the top ten things medical providers should keep on their radar for 2026.

1️⃣ What is APM status — and can you change it?
Advanced Alternative Payment Models (APMs) are CMS-approved models that reward physicians for quality and cost efficiency rather than volume alone.
Examples include certain MSSP tracks, bundled payment models, and specialty-specific CMS Innovation models. Not all are available in each state. See https://qpp.cms.gov/eligibility-participation/apm/overview for more detail.

Why this matters in 2026:
• CMS now uses different conversion factors depending on whether you qualify as an Advanced APM participant
• APM participation can affect payment rates, reporting requirements, and incentives

How to change or pursue APM status:
• Most physicians cannot unilaterally elect APM status
• Status depends on participation in a qualifying CMS model and meeting payment or patient thresholds

Actions physicians can take:
• Join or form a qualifying ACO
• Evaluate CMS Innovation Center models relevant to your specialty. (See above.)
• Coordinate with billing, compliance, and leadership teams before the performance year begins

Translation: this is a strategic business decision, not a coding tweak. Generally, PCPs can be in only one. Specialists can participate in multiple.

2️⃣ Medicare is adding “efficiency adjustments.”
CMS finalized efficiency adjustments for certain non–time-based services. While E/M, care management, behavioral health, and many telehealth services are excluded, procedural-heavy practices should monitor how this affects margins.

Tip: Service mix matters more than ever.

3️⃣ Telehealth coverage is still evolving
CMS is simplifying how services qualify for the Medicare Telehealth Services List, focusing on whether the service can be safely delivered via interactive audio-video.
What to watch:
• Which services remain covered
• Documentation expectations
• Whether a service is permanent, conditional, or time-limited

Do not assume “it was covered last year” equals “it’s covered in 2026.”

4️⃣ Same-day preventive + problem visits require precision
Some payors are tightening rules around billing an E/M visit on the same day as a preventive service.

Key reminders:
• Modifier 25 must be fully supported by documentation
• Preventive codes ≠ problem-oriented E/M
• The medical record must clearly show separate and significant work

This is one of the most common denial triggers in private practice. Unfortunately, many billers believe that these services cannot be billed on the same day. Although there are limitations, most payors want patients treated. Beware though: because many items in wellness exams are included in E/M, levels 4 or 5 are routinely denied even with modification. You can't count elements twice on the same day.

5️⃣ “Started but not completed” procedures need correct modifiers
For reduced or discontinued procedures, Some payors apply different reimbursement percentages depending on the modifier used (52, 53, 73, 74).
Billing lesson:

The modifier choice must match the clinical scenario, or payment reductions (or denials) follow.

6️⃣ Dual-eligible billing workflows are changing
Some Medicare-Medicaid members are moving into more integrated plans, meaning:
• Claims routing may change
• Medicare and Medicaid services may be billed to a single plan

Front-office and billing staff must update payer routing or risk avoidable rejections. In Tennessee, TennCare is almost never the secondary payor!

7️⃣ TennCare programs have their own billing rules
If you participate in TennCare programs such as Tennessee Health Link, billing rules are governed by program-specific manuals — not just standard CMS guidance.

📘 Tennessee Health Link Provider Operating Manual
https://www.tn.gov/tenncare/providers/health-link.html

If you participate, this manual is required reading, not optional.

8️⃣ CMS Annual Wellness Visit vs ACA Preventive Services (they are NOT the same)
This is a frequent source of confusion. Talk with your customer service representatives to understand the rules of your major payors.

CMS Annual Wellness Visit (AWV):
• Medicare-only benefit
• Focuses on risk assessment, prevention planning, and cognitive screening
• No physical exam
• Codes:
• G0438 (initial AWV)
• G0439 (subsequent AWV)
Example billing:
Medicare patient receives an AWV with health risk assessment and prevention plan → bill G0439

ACA Preventive Services:
• Required under the Affordable Care Act
• Applies mainly to commercial plans
• Includes physical exam elements, age-based screenings, and counseling
• Codes:
• 99381–99387 (new patient)
• 99391–99397 (established patient)

Example billing:
Commercially insured patient receives annual physical with preventive screenings → bill 99396
Mixing these up almost guarantees a denial.

9️⃣ Balance billing rules still apply (even when it feels logical)
Federal and payer-specific balance billing protections apply in many situations. Private practices need:
• Clear financial policies
• Consistent staff scripting
• Documentation when services are non-covered
Surprises lead to complaints — not collections.

REMEMBER THE VALUE OF EACH PATIENT TO YOUR PRACTICE. Follow the rules but remember the patient is more important than the immediate dollar. THE PATIENT IS YOUR REASON FOR BEING!

🔟 Clean claims still win
In 2026, the highest-ROI improvements are still the basics:
• Accurate eligibility
• Correct payer routing
• Clean modifiers
• Strong documentation
• Electronic workflows for authorizations and claim status
Boring? Yes. Profitable? Also yes.

Bottom line:
Billing success in 2026 isn’t about working harder — it’s about working smarter, earlier, and with the right rules in mind.