Hey, it’s Athena,
The uninsured wave just hit the national data
Two weeks ago we showed you where Q2 earnings said the subsidy cliff landed: Tenet reported 80% to 100% of its lost exchange volume converting straight to uninsured. That was two health systems. Now the whole-industry data agrees.
The latest Kaufman Hall/Vizient National Hospital Flash Report, built from 1,300+ hospitals, shows uncompensated care up 17% year to date versus the same period in 2025, and still climbing month over month. As a share of gross revenue, it is up 8%. The year-to-date median operating margin sits at 2.5%, down 6% from the first half of 2025.
Here is the part that matters for this list: June outpatient revenue rose 8% month over month while inpatient rose 2%. Volume keeps shifting to your side of the building at the same time coverage is eroding underneath it. More patients in your chairs, more of them uninsured or about to be.
Every one of those accounts was billable at some point. A patient whose exchange plan lapsed in June still shows "active" in a stale eligibility file, gets scheduled, gets treated, and becomes an unpaid balance ninety days later. The write-off happens at check-in, months before finance sees it. Eligibility verification, coverage discovery, and point-of-service collection are the highest leverage work in your building this quarter, and the gap between organizations that rerun eligibility at scheduling, at confirmation, and at arrival versus once at booking is about to show up in these numbers.
Let's dive into it.
This Week's Reads
Two from the exactrx.ai archive that this week's news made relevant again.
Medicare Advantage Denial Rates 2026: The Appeals Economy: we argued MA denials were being written off at scale. KFF just put a number on it.
No Surprises Act IDR Final Rule 2026: the $15 fee and the batching rules, which just got a lot more interesting. See item one below.
Modifier 59: When to Use It, When to Leave It Off, and the Other Modifiers That Put Your Revenue at Risk: OIG found 40% of code pairs billed with 59 failed Medicare requirements, about $59M a year. Which indicator actually lets you bypass an edit, why XU utilization is now getting the same scrutiny 59 used to, and the four failure patterns auditors look for.
Deals Tracker
Savista acquired ABW Medical, an ambulatory RCM firm serving FQHCs, community health centers, physician groups, and MSOs, heavy in the athenahealth ecosystem. Savista runs acute-care RCM for 800+ clients in 49 states, and this is its move into outpatient. Terms undisclosed. (Aug 27)
Arintra raised $25M Series B led by Define Ventures for autonomous medical coding inside Epic and athenahealth, claiming 5%+ revenue uplift and 43% fewer coding-related denials. Capital keeps concentrating on taking humans out of the coding loop. (Aug 24)
Regent Surgical Health acquired Integrated Surgical Center of Arizona, a Phoenix-area multispecialty ASC focused on cardiovascular, GI, and specialty surgery. Cardiac in the ASC is the most complex billing frontier in outpatient surgery, and Regent is scaling it. (Aug 26)
Physician owners of Atlas Surgery Center, an ambulatory neurosurgery center in Amherst, NY, proposed selling a 60% stake for $54M, with physicians keeping medical decision-making. A rare disclosed valuation datapoint for a physician-owned ASC recap. (Aug 28)
Cityblock Health acquired Homeward Health in an all-stock deal combining urban Medicaid/dual-eligible care with Homeward's ~50,000-member rural Medicare Advantage business, alongside a $116M Series E led by General Catalyst. (Aug 21)
Also worth noting: McKesson is acquiring Precision Medicine Group for ~$2.25B, a clinical research and biopharma commercialization firm that will sit inside McKesson's Oncology & Multispecialty segment, the corner of the market with the most complex outpatient billing (Aug 25). And the Sanford Health and North Memorial merger cleared under a 10-year Minnesota oversight agreement with $600M in committed investment (Aug 28).
What to Watch Next
The QPA guidance CMS promised still hasn't landed, and a clock is running. Three weeks after the Fifth Circuit struck ghost rates from the QPA formula, no revised FAQs and no new rulemaking. The existing relief, FAQ Part 73, covers old-methodology QPAs only for services through September 30. HFMA's advice: preserve all objections to QPA calculations that appear to rely on ghost rates. And a Georgetown analysis says IDR generated more than $22.4B in added costs since 2022; provider groups answer that a benchmark just ruled unlawful makes a poor baseline. Inventory your open IDR cases now.
DOJ put a $541.5M price on diagnosis codes. The Villages Health System settled False Claims Act allegations over diagnosis codes submitted to Medicare Advantage plans from 2020 to 2024 that lacked record support or came from unapproved chart amendments. The provider self-disclosed, cooperated fully, and still ended up in Chapter 11. Three days later CMS said it prevented $1.6B in fraudulent lab payments using AI to flag upcoding. Enforcement is going algorithmic, and the chart either supports the code or it doesn't.
Two deadlines for the calendar. Comments on the CY2027 Physician Fee Schedule close September 14, with the conversion factor dropping 1.68% for most clinicians as the one-year 2.5% statutory bump expires. And October 1 brings the FY2027 ICD-10-CM update: 190 new codes, 30 deletions, 4 revisions. Your coders have a month.
Ask Exactrx:
Last issue's Q&A got more replies than anything we've run, so we're keeping it going.
Q. "I am having denials with these two codes. The denial I receive is 'the primary service code was not submitted therefore the secondary code is not allowed. The information submitted on the claim is inconsistent with current coding protocol.' I am billing CPT 15771 (1st 50 units fat) then the add-on code 15772 for the additional 50 cc units for a total of 100 cc. What am I missing?"
A. The denial names 15772, but the problem lives on the 15771 line. An add-on code never adjudicates on its own: when the payer says the primary "was not submitted," it means it couldn't find a payable parent line. So pull the remit and read the 15771 line first. Most BCBS medical policies cover autologous fat grafting only for named reconstructive indications, post-mastectomy reconstruction being the big one. If the diagnosis doesn't land inside the policy, the parent dies quietly and the add-on denial is the only thing that looks loud.
Then the mechanical checks. Both codes on the same claim, same date of service, same rendering NPI, 15771 first. Units: 100 cc is 15771 x1 plus 15772 x1, never 15771 with two units. And confirm the code family matches the site: 15771 and 15772 cover the trunk, breasts, scalp, arms, and legs in 50 cc increments, while face, hands, and feet belong to 15773 and 15774 in 25 cc increments. Graft to the face billed under the trunk family reads to a payer exactly like "inconsistent with current coding protocol."
The rule worth keeping: when an add-on code denies, stop looking at the add-on. Diagnose the parent.
Upcoming Events
Becker's Health IT + Digital Health + RCM, Sept 14 to 17, Hilton Chicago. Themed on AI in the revenue cycle. Reply if you're going.
TASCA Fall Conference & Trade Show, Sept 24 to 25, Hilton Knoxville. We're based in Brentwood, so the TASCA calendar is close to home for us. Regulatory updates, credentialing, AAAHC citations, and financial analysis, with CE for nurses and administrators. Early registration and the $199 room block both close August 31.
So: what's your appeal rate? If you know it off the top of your head, you're ahead of most of this list. If you don't, that's the week's project, and I'd genuinely like to hear what you find. Hit reply.
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.