VAB RCM

06/24/2026

The two-week operation uncovered more than $6.5 billion in false claims submitted to insurers, according to the Department of Justice. State authorities made nearly two dozen arrests.
More than two dozen people from Florida were among 455 individuals charged in a $6.5 billion health care fraud and insurance scheme during a two-week federal enforcement operation, authorities announced.

Florida cases included a cardiologist accused of billing insurers for medically unnecessary screening tests for college athletes; three Tampa-area healthcare workers in a $118 million Medicare fraud involving unnecessary wound care and skin grafts; and a Miami man who directed a $3.76 billion scheme that billed Medicare, Medicaid and other insurers for phantom medical supplies.

Healthcare fraud has been a long-running priority for the Department of Justice, and news conferences announcing roundups and crackdowns have been common across the years. The Trump administration has made a point of emphasizing enforcement, including through the appointment of a new assistant attorney general, Colin McDonald, to help oversee prosecutions built from multiple specialized task forces.

“Today’s cases allege more than the theft of taxpayer dollars. Many allege the theft of human dignity,” McDonald said at a news conference Tuesday announcing this year's crackdown, which covers cases charged or unsealed since June 8. “Our sick, needy and elderly placing their faith in the gift of medicine were neglected, ignored and used for personal profit.”

The two-week operation uncovered more than $6.5 billion in false claims submitted to insurers, according to the Department of Justice. State authorities made nearly two dozen arrests.

06/14/2026

AI in medical billing / revenue cycle management

The most important June story so far is that AI-enabled documentation and coding may be raising medical bills rather than lowering costs. PwC’s June 2026 medical-cost outlook, reported by Axios and Healthcare Dive, says medical costs are projected to rise 9% in the employer market and 8.5% in the individual market next year, with AI documentation and coding tools among the inflators.

The mechanism is simple: AI scribes and coding systems capture more diagnoses, comorbidities, and complexity, allowing providers to bill at higher levels even when the underlying care may not have changed.

For all of the ways AI could meaningfully improve patients' lives, making care more affordable isn't one of them.

05/17/2026

The clock is ticking on Q-Day, the looming yet unknown date when quantum computing will have the capacity to quickly and easily break the encryption keys that keep most internet communication safe.

Experts have known about the hypothetical risk of Q-Day since the 1990s. But Google recently warned that quantum computers may be able to hack some encrypted systems by 2029 — a timeline that drastically narrows the window to safeguard data that many cybersecurity specialists had previously predicted. The new estimate means that governments, companies and other entities may have far less time to prepare.

The day when a quantum computer can crack commonly used forms of encryption is drawing closer. The world isn’t prepared, experts say.

05/15/2026

UnitedHealthcare (UHC) is the largest health insurer in America, covering more than 29 million people, according to the American Medical Association (1). Unfortunately, as CNBC reported last year, it has also become the "face of America's health insurance frustrations" (2).

The fatal shooting of the company's CEO Brian Thompson in December of 2024 brought to the forefront the intense frustrations people have with UHC. In fact, his death prompted calls for reforms and criticisms of the insurance industry's focus on profits over people.

UnitedHealthcare is taking a big step to make healthcare access easier.

05/13/2026

Billing frustration is concentrated among younger patients.

63% of patients aged 25–34 hit at least one billing problem, vs. just 14% of those 65 and older. 30% of patients aged 25–34 found billing confusing or worse — nearly four times the rate of those 65 and older.

Healthcare

05/04/2026

Key Takeaways CMS 2026 Regulations Medical Billing Changes

Discover how CMS 2026 Regulations will reshape Medical Billing for independent practices, from audits to reimbursement, so you can protect revenue.

05/01/2026

Traditional Medicare prior authorization has entered a new phase through WISeR

The CMS WISeR (Wasteful and Inappropriate Service Reduction) Model came about in 2026 and is especially important because it brings a prior-authorization / pre-payment review logic into parts of Original Medicare, historically much less authorization-heavy than Medicare Advantage. CMS says providers and suppliers in selected regions may submit prior authorization requests for covered model services or go through post-service/pre-payment review. CMS also says the model uses enhanced technologies, including AI and machine learning, combined with clinician review.
KFF (formerly known as Kaiser Family Foundation, a health policy think tank) notes that prior authorization is routine in Medicare Advantage and private insurance but rare in traditional Medicare, and warns that it can create delays, denials, uncertainty, and administrative costs for providers.
Practical implication: for clients in affected specialties and regions, billing companies need a WISeR checklist: covered services, documentation standards, authorization pathway, appeal process, and payer-review tracking.

Wasteful and Inappropriate Service Reduction (WISeR) Model webpage

04/27/2026

As of April 2026, the medical billing / RCM industry is being shaped by a convergence of prior authorization reform, Medicare rule changes, cybersecurity pressure, denial management, AI, and No Surprises Act compliance.

A major current development is the movement toward standardized and electronic prior authorization. On April 24, 2026, that UnitedHealth and CVS Health have standardized data and submission requirements for more than half of their prior authorizations, as part of a broader insurer initiative to reduce delays and administrative burden. This matters directly to billing companies because prior authorization is becoming a front-end revenue-cycle competency, not merely a clinical-office task.

CMS is also pushing electronic prior authorization through its interoperability framework. CMS’s electronic prior authorization page, updated recently, points providers to the 2026 interoperability standards and prior authorization proposals, while CMS’s April 10, 2026 proposal would extend certain interoperability/prior authorization requirements to small-group market QHP issuers on the federally facilitated SHOP marketplace.

Practical implication: billing companies should treat prior authorization as a billable, trackable workflow with payer-specific rules, appeal templates, evidence packets, and turnaround-time monitoring.

US News is a recognized leader in college, grad school, hospital, mutual fund, and car rankings. Track elected officials, research health conditions, and find news you can use in politics, business, health, and education.

04/14/2026

Modern Healthcare just released the 2026 100 Top Hospitals® list. This annual program uses a data-driven methodology to identify the nation's top-performing hospitals, evaluating clinical outcomes, operational efficiency, financial health, and patient experience.

Also recognized is the Everest Award — a special distinction honoring hospitals that have achieved both the fastest rate of improvement and the highest current-year performance on the balanced scorecard over a five-year period.

Congratulations to all the hospitals and their boards, executives, and medical staff who earned a spot on this year's list.

For over 30 years, the 100 Top Hospitals® program has been producing annual, quantitative studies designed to shine a light on the nation's highest performing hospitals and health systems.

04/11/2026

Touchless Revenue Cycle
Healthcare revenue cycle management (RCM) remains one of the most labor-intensive and costly aspects of healthcare delivery. It accounts for 3–4% of a typical health system's net revenue, translating to more than $140 billion annually across U.S. systems. Traditional automation has delivered incremental gains, but persistent challenges such as high claim denial rates (averaging nearly 20%, with up to 60% never appealed), fragmented technology vendors, manual workflows, and rising labor costs continue to strain operations and delay cash flow.

Enter agentic AI, a significant evolution beyond generative AI. While generative AI primarily creates content or offers advisory insights, agentic AI consists of autonomous AI agents that can perceive, reason, plan, make decisions, and execute complex, end-to-end processes with minimal human supervision — essentially acting as a digital coworker. These agents learn from patterns in rules-based tasks, handle interconnected workflows, and operate under human oversight for exceptions, compliance, and refinement. In RCM, this enables a vision of a "touchless revenue cycle": a self-running system where administrative tasks flow seamlessly with little to no manual intervention, from front-end scheduling through mid-cycle documentation and coding to back-end claims and collections.

In their 2026 report, McKinsey points out that agentic AI offers the first credible path to truly tech-enabled RCM by shifting from narrow task automation to holistic workflow ex*****on. Initial deployments often focus on the back end — where processes are highly rules-governed, labor-intensive, and lower-risk — before expanding across the full cycle. Key use cases include:

Accounts receivable follow-up: Automating high-volume claim status monitoring and outreach to reduce labor hours while processing more claims accurately.

Underpayment and denials management: Identifying patterns, assembling appeal documentation, drafting submissions, and improving overturn rates.

Cash posting and collections: Handling routine payments and patient reminders, freeing staff for strategic work.

These applications leverage agentic AI's ability to orchestrate multi-step tasks, integrate with existing systems, and adapt based on outcomes. Over time, interconnected networks of agents could span the entire cycle — eligibility checks, prior authorizations, coding from clinical documentation, and patient billing — creating a more unified, efficient engine.