Hey, it’s Athena,

….Q2 answered where the ACA subsidy cliff lands

Exchange patients aren't moving to another plan. They're going uninsured.

Tenet's hospital segment took a 17% drop in exchange revenue. CFO Sun Park said exchange admissions fell about 13.5%, with roughly 80% to 100% of that volume converting straight to uninsured. HCA saw the same 15% swing and cut 2026 guidance on a $1 billion to $1.2 billion ACA headwind.

Meanwhile Tenet's USPI ambulatory arm grew adjusted EBITDA about 9% to $542 million. HCA's ASC earnings grew in H1. Hospital outpatient surgery fell 3.4%.

This is a front end problem. Every point of exchange to uninsured conversion turns a billable claim into a patient balance you won't collect. Eligibility and financial clearance are now the highest leverage work you have.

Let’s dive into it.

The articles published this week on exactrx.ai dig into what that means operationally, and what it looks like when payers get there first. This week we have two new articles, one on stopping denials before they start, one on building a center the right way.

The CY2027 OPPS/ASC rule adds ~618 procedures to the ASC Covered Procedures List, pulls ~637 off Inpatient Only, and puts eight botulinum toxin codes under prior auth starting July 2027. Your case mix changes next year whether you planned for it or not.

We built a one pager on which additions matter by specialty. Reply "OPPS" and I'll send it.

Also worth noting: Transform Health Partners picked up two Washington bariatric practices (Aug 4), and Lee Health acquired Gardner Orthopedics (Aug 3). Health systems and MSOs are still competing for the same ortho and surgical assets.

1. The feds found a modifier problem. Ophthalmic Consultants of Boston paid $3.9M to settle allegations it billed office visits alongside intravitreal injections using a modifier that requires specific supporting documentation it didn't have. Ten years of claims. That's four ophthalmology enforcement actions in two weeks. Nobody sets out to bill a modifier wrong. It happens when documentation and coding drift apart across thousands of encounters and nothing checks the pair before submission.

2. DOJ just made an MSO example. DOJ declined to prosecute Campus Eye Management, a billing and management company serving an optometry practice and an ASC, but indicted its founder over $3.4M in claims tied to referral-linked management fees. First healthcare declination under DOJ's new self-disclosure policy. The fact pattern is common across PE-backed roll-ups, and comparable theories are surfacing in vein, dental, and anesthesia.

3. 73% of health plans lost money in 2025, up from 54% in 2023. 83% among Blues. Payers losing money don't loosen utilization management. Your Q4 denial budget is optimistic.

Exactrx has grown fast over the past few months, and the community you've built around this newsletter is my favorite part of it. Your replies turned into a real Q&A, so I'm making it a section.

First up: splitting a global on an out-of-state patient.

Q. "Patient lives out of state, came through the ED, we ORIF'd a fracture. He was inpatient a week and our providers rounded on him daily, then went home to follow up locally. I know the surgery gets a 54. How do we bill the rounding visits?"
— Anonymous Medical Biller

A. Bill this on two lines with the same CPT on both, with the date of surgery as the date of service on each. Line one carries modifier 54, and modifier 55 goes on line two. The span of post-op days your providers furnished belongs in Item 19. Confirm the inpatient portion with your MAC before submission, since the relinquish-at-discharge guidance is written around the 54 line alone and the treatment of surgery-to-discharge days remains unsettled. Review the chart for the initial inpatient E/M as well. If that visit produced the decision to operate, it is separately billable with modifier 57, and providers forfeit that line more often than any other in this scenario. Advise the hometown provider against G0559, which applies where no formal transfer occurred and cannot be reported alongside a 55. One last thing: the two MAC payments will not sum to the global amount. That difference is GPCI, rather than an underpayment.

Got a scenario you want worked through? Reply with it. The good ones run here.

This newsletter goes out to a focused group of operators, finance leaders, and revenue cycle professionals working in ambulatory and outpatient settings. If someone forwarded this to you and it felt relevant, it probably was.

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