The year 2025 marks one of the largest shifts in the Medicare ecosystem in decades, particularly due to reforms that arise from the Inflation Reduction Act. The introduction of reforms designed to lower costs and increase access to care will have a ripple effect on providers and billing companies alike. In order to stay compliant and optimize revenue cycle management, billing companies are going to have to anticipate the forthcoming reforms. Out-of-Pocket Prescription Drug Costs Limited to $2,000 One of the most significant changes is the introduction of $2,000 cap on out-of-pocket prescription drug copays per year as part of Medicare Part D. Medicare beneficiaries are often faced with high costs, and the implementation of a lower drug copay burden will help alleviate the financial burden for seniors. As a continual change, medical billing companies should prepare for such a change in advance and keep in mind future changes to billing formats and payment structures. Preparation: – Update systems to changing prescription drug billing codes and structures. – Prepare up-to-date communication for patients on how this changes prescription costs in regard to their existing costs. Potential Changes to Medicare Advantage Plans Medicare Advantage (MA Plans) are insurance policies that offer an alternative for coverage under traditional Medicare and may involve increased premiums and increased or unlimited copays. Copay increases may result from the increased cap under the introduction of drug costs or limited government payment increases wherein the insurer raises options that may involve increased deductibles or some limited benefit offerings by way of MA permits. Billing companies may also experience information on the permitted formularies to include in their service offerings to improve recovery rates. A billing company needs to be aware of both formulary structures and ICN, PIN, or other networks on how they function either with one company or multiple insurers. Preparation: – Monitor the changes of MA insurers becoming more prevalent in the dual eligibility models due to the underlying political dynamics (Biden administration), limit benefits combined with increase structures.. – Educate staff on procedural implications of MA. 3. Opt-In Payment Plan for Drug Costs A new opt-in payment plan will allow beneficiaries to spread out their drug costs over several months rather than paying all at once. This shift could impact how billing departments manage payments, as patients may choose different payment structures. Preparation: – Implement systems to manage monthly billing for patients opting for this payment plan. Communicate effectively with patients to ensure they understand their payment options and stay on track with monthly payments. 4. Part B and Part D Premium Changes With expected increases in Part B and standalone Part D premiums, medical billing companies need to be prepared for patients’ concerns about rising healthcare costs. Stabilization measures from the government aim to limit fluctuations, but the increases may still affect billing and reimbursement rates. Preparation: – Review billing contracts to ensure they align with the adjusted premiums and rates. – Stay updated on premium changes to assist patients and providers with accurate billing and insurance verification. 5. Telehealth and Home Health Coverage Medicare is likely to continue expanding telehealth services, with new billing codes potentially being introduced to accommodate increased telehealth visits. Additionally, Medicare may expand value-based payment models for home health services. Preparation: – Ensure that EHR and billing systems are up-to-date with the latest telehealth and home health billing codes. – Educate staff on the new reimbursement models for telehealth and home health services to optimize billing efficiency. 6. Expanded Access to Lower-Cost Biosimilars CMS is working on finalizing policies to increase access to biosimilar drugs, which are often cheaper alternatives to brand-name biologics. This change could influence prescription billing codes and reimbursement rates. Preparation: – Update your coding systems to reflect changes in biosimilar drug coverage and pricing. Collaborate with pharmacies and providers to ensure smooth billing transitions for biosimilars. Medicare Advantage Unused Benefits Mid-Year Notices From 2025, Medicare Advantage enrollees will get mid-year notices on unspent extra benefits. The new guidance is designed to help ensure that patients have a better understanding of the type of coverage their plan provides. Preparation: Monitor and conform billing practices depending on the potential utilization increase as their benefits are recognized by patients. How to Stay Ahead Coordinate with Medicare Advantage plans for changes in policy that will impact billing practice. Learn About Improving Your Mental Health Increase availability of mental health professionals in Medicare (including addiction counselors and therapists) This development will necessitate expanded billing codes for these vital mental health services. Preparation: Make sure billing systems include new mental health services and providers Educate your staff on proper mental health billing codes, so you can focus on avoiding denials and getting paid quickly. Prior Authorization Approvals Audit Medicare Advantage plans should review their current prior authorization policies, especially in regards to high-risk populations. The authorization process might change and could ultimately delay time to approval and reimbursement for billing companies. Preparation: Incorporate the prior authorization in your billing workflow. Track changes in policies of the insurance houses, so that you can process your claims in time and they do not get rejected. Conclusion It is said that the changes to Medicare in 2025 will improve affordability, extend coverage and simplify care. But these updates have implications for medical billing companies, which are obligated to change up their systems and flows in order to remain compliant and run efficiently. With proper preparation and appropriate technologies in place, billing companies can continue business as usual while maximizing the potential these changes represent.
