Gratitude & Guidance: November Insights from MRCS

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November offers a natural moment to reflect on the progress made throughout the year and recognize the people and partnerships that helped make it possible. It is also an important time for healthcare organizations to review current priorities, address year-end requirements, and prepare for changes taking effect in 2027.

This month’s healthcare observances bring attention to the patients, caregivers, families, and professionals navigating chronic conditions, supporting care at home, and making a difference across the healthcare community. They also remind us that awareness is most meaningful when it leads to greater understanding, stronger support, and thoughtful action.

In this month’s newsletter, we’re sharing timely deadlines, Medicare and payer updates, broader healthcare policy developments, practical resources, and MRCS highlights to help your organization stay informed, address current requirements, and prepare for 2027 as the year begins to wind down.

We begin by recognizing several November observances that highlight the people, experiences, and areas of care deserving greater awareness.

🔔 Immediate Action Items for November

November brings several important Medicare, Medicaid, enrollment, compliance, and year-end deadlines. We’ve highlighted the items most likely to affect your organization’s billing, reimbursement, eligibility, reporting, and payer workflows.

Review the CY 2027 Medicare Physician Fee Schedule Final Rule

CMS released the CY 2027 Medicare Physician Fee Schedule Final Rule on November 4. The qualifying APM conversion factor is $32.9548, a 1.83% decrease from 2026, while the nonqualifying APM conversion factor is $32.6286, a 2.31% decrease. These reductions reflect, in part, the expiration of the temporary 2.5% payment increase provided for 2026.

The rule also finalizes a 20% reduction for other services when a separately identifiable office/outpatient E/M visit and a 0-day global procedure are billed together, replaces HCPCS code G2211 with modifiers B1 and B2, updates requirements for remote patient and therapeutic monitoring, and ends traditional MIPS as a reporting option after the 2030 performance period. Practices should review the finalized payment, coding, quality-reporting, and operational changes taking effect January 1, 2027, and evaluate the potential financial and workflow impact.

Verify Your Medicare HETS Email Address by December 1 Organizations that access Medicare eligibility information through a clearinghouse, billing company, EHR, or other vendor should confirm that the email address associated with their HETS EDI enrollment is correct. CMS may suspend enrollment when messages fail delivery for three consecutive months. Necessary corrections must be submitted through the provider’s Medicare Administrative Contractor.

Review Your Medicare Revalidation Due Dates

Enrollment teams should search the current Medicare Revalidation List for individual practitioners and organizations and begin working on revalidations within the permitted submission period. CMS posts upcoming due dates approximately six to seven months in advance, and providers should not submit a revalidation until a due date appears in the tool. Missing a deadline may result in Medicare payment holds or deactivation of billing privileges.

Review Your 2025 MIPS Feedback and Request a Targeted Review by November 30 CMS has released 2025 MIPS final scores and 2027 payment-adjustment information. Practices should sign in to the Quality Payment Program website to review their final scores and verify the resulting payment adjustments. Scores above 75 result in a positive adjustment, a score of 75 results in a neutral adjustment, and scores below 75 result in a negative adjustment. If you believe CMS made an error, submit a targeted-review request by November 30, 2026, at 8 p.m. ET.

🩺 Specialty Provider Alert

Review Additional CY 2027 Medicare Final Payment Rules

CMS also finalized CY 2027 payment and policy updates for hospital outpatient departments, ambulatory surgical centers and home health agencies. OPPS and ASC payment rates will increase by 2.3% for organizations meeting applicable quality-reporting requirements, while Medicare payments to home health agencies are projected to increase by approximately 2.4%. The rules also include changes affecting 340B drug payments, outpatient service settings, quality reporting, Medicare enrollment, home health operations and DMEPOS policies. Affected organizations should review the final rules and evaluate the reimbursement, compliance and workflow changes taking effect in 2027.

ESRD Facilities: Review CY 2027 Payment Changes and the December 31 LVPA Deadline CMS finalized a $297.52 ESRD PPS base rate for 2027 and projects an approximately 2.7% increase in total payments to ESRD facilities. The rule also includes changes affecting low-volume, pediatric, home and self-dialysis training, drug-payment, and quality policies. Qualifying facilities seeking the Low-Volume Payment Adjustment for 2027 may submit their attestation through December 31, 2026.

📍 Maryland Medicaid Provider Alert

Confirm MPRIME Enrollment and Account Access Maryland Medicaid providers should confirm that appropriate staff can access MPRIME and that enrollment, revalidation, affiliation, and provider-record activities are being completed through the correct system. Practices should also address pending applications or updates that could affect Medicaid participation or claims.

🧾 Payer Alerts

Complete CareFirst Model of Care Training and Attestation by December 31

Providers who see CareFirst Advantage DualPrime members must complete the annual Model of Care training and attestation by December 31, 2026. Practice-level attestation is permitted. Select “Model of Care” on CareFirst’s Government Programs On-Demand Training page to access the course.

Review CareFirst Enrollment and Post-Acute Authorization Updates

Confirm that the billing NPI used on claims is active in NPPES and enrolled with CareFirst. Beginning December 1, 2026, post-acute authorization requests must use the applicable CPT or HCPCS code instead of a revenue code.

CareFirst CHPMD: Review Current and Upcoming Authorization Changes

Beginning November 2, 2026, providers may submit and track medication prior authorization requests electronically through the CareFirst Provider Portal and NovoLogix. When commercial coverage is primary and Medicaid is secondary, providers must follow the commercial plan’s authorization requirements first.

Beginning January 1, 2027, the current $500 threshold for determining durable medical equipment prior authorization requirements will be removed. Advanced diagnostic imaging will also require prior authorization regardless of the place of service. Providers should use the Prior Authorization Lookup tool in the CareFirst Provider Portal to verify requirements before providing services.

Review UnitedHealthcare’s December 1 Prior Authorization Changes

Beginning December 1, 2026, UnitedHealthcare will remove prior authorization requirements for select services provided to patients under age 18 under applicable commercial, Individual Exchange, and Community Plans. UnitedHealthcare will also end outpatient radiology site-of-service reviews for applicable commercial, Individual Exchange, and Oxford plans, as well as the UnitedHealthcare Community Plan of North Carolina. Because requirements vary by plan and location, practices should continue verifying each service through the UnitedHealthcare Provider Portal.

AmeriHealth Caritas DC: Obtain Non-Emergent Authorizations in Advance Effective November 1, 2026, AmeriHealth Caritas DC will no longer routinely approve retrospective authorization requests for non-emergent services that required advance approval. Practices should verify requirements and obtain authorization before scheduling or providing applicable services.

🔍 Key CMS & Healthcare Industry Updates

Several broader developments may influence reimbursement, claims administration, access to care, and strategic planning as healthcare organizations prepare for 2027.

CMS Finalizes Mandatory Medicare Part B Drug Payment Model The mandatory five-year GLOBE Model begins January 1, 2027, and will test a new rebate formula for selected Medicare Part B drugs in areas representing approximately 25% of Original Medicare beneficiaries. Practices that administer Part B drugs should monitor CMS guidance on participating areas, included drugs, and potential effects on beneficiary cost-sharing.

Prepare for Electronic Prior Authorization Changes in 2027

Beginning January 1, 2027, affected Medicare Advantage, Medicaid, CHIP and Marketplace payers must implement electronic prior authorization and healthcare-data exchange capabilities. CMS and the Department of Labor are also encouraging broader adoption among self-funded employer plans. Practices should coordinate with their EHR and other technology vendors to prepare for updated authorization workflows. CMS is separately testing technology-assisted reviews through the WISeR Model, which does not currently operate in Maryland.

CMS ACCESS Model Expands Technology-Supported Chronic Care

Primary care and referring clinicians can connect eligible Original Medicare patients with ongoing, technology-supported care for conditions such as high blood pressure, diabetes, chronic musculoskeletal pain and depression. Services may include remote monitoring, coaching, lifestyle support and medication management at low or no cost to patients. Eligible Medicare Part B practitioners do not need to participate in the model to refer patients. They may bill a Co-Management Payment after reviewing an ACCESS care update and completing and documenting at least one related care-coordination activity, with a minimum of five minutes of total practitioner time.

Review Medicare Remittance Advice Code Updates

CMS has updated the Remittance Advice Remark Codes and Claim Adjustment Reason Codes used to explain Medicare claim payments and adjustments. Billing teams should review the October updates and watch for applicable software updates if they use Medicare Remit Easy Print or PC Print.

Maryland Receives $16.4 Million for Rural Healthcare Workforce Development CMS announced $16.4 million to support rural healthcare workforce training, provider recruitment and retention, community-based care, and healthcare technology across Maryland.

CMS Clarifies Telehealth Billing for RHCs and FQHCs Effective October 1, 2026, Rural Health Clinics and Federally Qualified Health Centers must report the applicable CPT or HCPCS code and telehealth modifier for distant-site services instead of HCPCS code G2025. Affected organizations should confirm that billing and documentation workflows reflect the change.

💡 MRCS Revenue Cycle Quick Tip

Year-end accounts receivable cleanup should begin before December. Run an aging report and identify unresolved claims approaching timely filing or appeal deadlines.

Review the list weekly through year-end. Addressing these high-risk balances now can help prevent avoidable write-offs, improve cash flow, and give your organization a cleaner financial start to 2027.

🎤 MRCS in Action: That’s a Wrap on the 2026 Conference Season

Kem Tolliver, FACMPE, CPC, CMOM, closed a busy 2026 conference season by sharing practical revenue cycle guidance with healthcare professionals in Nashville and New Orleans.

Taking Center Stage at UFinity 2026

On November 2, Kem concluded her 2026 conference speaking engagements in Nashville as a keynote presenter at UFinity Conference 2026, hosted by Unlimited Systems.

In Lead Where You Are: Taking Center Stage in Revenue Cycle, Kem encouraged healthcare professionals at every level to recognize the influence they have on patient experience, financial performance, and organizational success.

Her presentation explored the hidden financial and human costs of disconnected workflows, the downstream effects of process breakdowns, and the importance of correcting workflows before introducing new technology. She also emphasized that successful technology adoption depends on team involvement, meaningful training, and actionable feedback from the people who use these systems every day.

Kem closed with a practical challenge: Choose one workflow. Take one step. Lead where you are.

We extend our appreciation to Unlimited Systems, the UFinity conference team, and the attendees who helped make Kem’s final conference presentation of 2026 a meaningful conclusion to the season.

Kem Tolliver presents “Lead Where You Are: Taking Center Stage in Revenue Cycle” at UFinity Conference 2026 in Nashville.

Practical Revenue Cycle Guidance at NORM

On October 1-3, Kem represented MRCS at the 2026 National Organization of Rheumatology Management Annual Conference in New Orleans.

During the conference, she led the general session Revenue Cycle Management Work Plan for Rheumatology Administrators, helping practice leaders consider how a structured work plan can bring greater focus, accountability, and consistency to revenue cycle operations.

Kem also presented A Foundational, Step-by-Step Approach for Revenue Cycle Management for New Managers. The breakout session helped newer leaders understand the complete revenue cycle, identify specialty-specific risks, establish workflow ownership, and begin improving one process at a time.

We appreciate NORM for the opportunity to support rheumatology practice leaders with practical strategies they can bring back to their organizations.

Kem Tolliver shares practical revenue cycle guidance with rheumatology practice leaders during the 2026 NORM Annual Conference in New Orleans.

Closing a Meaningful Year of Education and Connection

Throughout 2026, Kem represented MRCS at national conferences and regional educational programs, as well as through webinars, virtual certification trainings, and podcast interviews. Each engagement provided an opportunity to share knowledge, exchange ideas, and connect with professionals working to strengthen their organizations and better serve patients.

We are grateful to every organization, conference team, professional association, podcast host, fellow presenter, and attendee who welcomed MRCS into these important conversations throughout the year. As the 2026 conference season ends, we look forward to continuing this work and creating new opportunities to learn, connect, and contribute in 2027.

📚 Turn Year-End Reflection into a Learning Plan

Through our partnership with Practice Management Institute, the MRCS Learning Center connects healthcare professionals with education and credentialing opportunities in revenue cycle management, coding, compliance, and practice operations.

What knowledge or credentials would help you contribute more effectively in 2027?

Learn More

🤝 Where Could Your Practice or Organization Use More Support?

Whether you are launching a new practice or strengthening an established organization, the right guidance can help you avoid costly missteps and build a stronger operational foundation. MRCS supports healthcare leaders with practice start-up and expansion, revenue cycle and practice management, payer contracting and enrollment, coding and compliance, workflow improvement, and healthcare technology optimization.

Explore MRCS Services or email admin@medrevenuecycle.com to start a conversation about focused guidance or broader operational support. You can also follow MRCS on LinkedIn for additional industry insights and updates.

🧡 Closing Thoughts

Progress in healthcare is rarely the work of one person. It is made possible by people who share their knowledge, support one another, and remain committed to serving patients and strengthening their organizations.

As Thanksgiving approaches in a few weeks, we are grateful to the clients, colleagues, partners, and healthcare professionals who allow MRCS to be part of their work. We value the trust you place in us, the perspectives you share, and the opportunities we have to learn and grow together.

We hope the weeks ahead bring meaningful moments with the people who matter most and renewed energy for the work still to come.

Thank you for being part of the MRCS community.

With gratitude, The MRCS Team