Key takeaways from this episode

• The CMS hold on Medicare telehealth claims is expected to lift Thursday, October 16, at the end of the 10-business-day count. Medicare funding is not the issue; the MACs are reprogramming for telehealth, hospital at home and the other COVID-era extensions that were not protected under the continuing resolution, and some MACs may start processing sooner.
• Payers will not reimburse credit card processing fees, so move every payer to ACH direct deposit. The standard payer response is "that is your cost of doing business, not ours"; ACH is the fastest, most secure and usually lowest-cost method, while paper checks are the least secure and cause delays that cost more than the per-transaction savings.
• Virtual credit card is the payer default, and only the practice can change it. Payers cannot set up ACH on their own; you have to contact each payer and supply bank information, or they will keep paying by credit card because it is easiest for them.
• Ask for a cost of living increase every year rather than chasing a processing-fee clause. A 5% rate bump is worth more than a 3% fee recovery; use the processing fee as one argument for the raise, and stagger payer negotiations through the year so the project is manageable.
• Getting paid today does not mean PECOS and CAQH are in order. Missed PECOS notifications (often from an old address or email) mean you are paid until the expiration hits, and reinstatement is difficult; assign someone in the office to check PECOS, CAQH, payer credentialing and facility privileges routinely.
• Credential new physicians and APPs with payers as soon as they join, not just with the hospitals. New providers must be added to your payer contracts, and every credentialing process is running slowly.
• For credentialing and contracting help, use a specialized service. PRS can refer practices to the groups it works with, and your state medical society and other urology practices are good sources of referrals.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 262, recorded October 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Government shutdown, day 10: where things stand

[00:00] Scott Painter: On this episode: the latest on the government shutdown, and how to stop paying processing fees on payer payments. Stay tuned. Welcome to episode 262 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. First, we want to update you on the government shutdown and where we are right now. As of this recording, it is Friday, October 10th. Mark, do you want to bring us up to speed on where we are and what's happening? I wish I could say what was going to happen, but what's happening now, and where do you think we're headed?

[01:00] Mark Painter: As the days count, it's day 10 of the shutdown because it's the 10th of October. So far there have been three Democrats that crossed over, and they need seven. Everybody else seems to be holding the line. The Senate was sent home yesterday and they won't be back until Tuesday. The House has yet to come back in to vote on any new changes, so we remain shut down. The pressure is increasing as the collateral issues pop in. Military paychecks are at risk of not getting paid. TSA and FAA work is being held up, so there's pressure outside of what's going on in healthcare. And of course our big issue right now in healthcare is telemedicine, or telehealth, which is currently not covered under traditional Medicare.

The hold on claims that was instructed by CMS is supposed to be up to 10 business days. When we count the business days, we're not at the end of the hold from the MACs. That will actually extend because of the two weekends plus the federal holiday on Monday. We expect that hold is going to lift on Thursday of next week, which I believe is around the 15th.

Scott: The 16th is Thursday.

[02:00] Mark: The 16th. It is a hold of up to 10 days, so there's a possibility that some of your MACs can start processing sooner if they get the programming changes done so they don't have to reprocess. That's making the adjustments to telehealth and the coverage of telehealth, as well as some of the changes to hospital at home and some of the other extensions that were part of the extended COVID rules to allow for coverage of telehealth. So it could happen sooner, but the 16th, next Thursday, is the 10 days of the hold as a business-day count. Everybody needs to plan for that. Again, the issue is not funding for Medicare. The issue is the reprogramming for those things that are no longer protected under the continuing resolution, which is telehealth and some of those other issues related to at-home care and some of the COVID extensions.

So we continue to watch to see what's happening, which in the end doesn't look like a lot, but I think we've got enough pressure from other areas that hopefully we'll start to see some action next week. I know the military paychecks are a big one. We're already starting to see issues and holes in the travel situation with the FAA and TSA. Those are mandatory workers, so they're supposed to get their back pay, and that is by regulation. They're going to get their back pay if they show up to work, but anybody who's living paycheck to paycheck is going to be skipping paychecks, and that's a tough thing for a lot of folks to do. So whether they take the day off and drive for Uber or Uber Eats or something like that is real. We're certainly seeing those impacts as people call in sick and figure out how to pay their bills while they're not getting a paycheck. With that pressure increasing with every day of the shutdown, maybe we'll start to see a little bit more willingness to actually meet and figure out a way to open the government again.

[05:00] Scott: All right, Ray. Comments, suggestions?

Dr. Ray Painter: Nothing. I don't even know how to express everybody's frustration with the politics of the hour.

Scott: Yeah, very frustrating. All right, stay tuned, and if we hear anything and anything changes, we'll send out a blast email to keep you posted.

Listener question: payers paying by credit card and charging processing fees

[06:00] Scott: Let's move on to our second topic. We got an email that asked if this might be a good subject for discussion, and we thought it was. Richard says: "The insurance companies pay us with a credit card, and when we cash it, we get charged a 3% fee, thus in fact reducing our income by 3%. We now ask for a physical check, but then they take a few weeks to send it, and sometimes they charge a processing fee. For direct deposit, they also charge a processing fee. How can we counteract this? Do we now have to stipulate in our contract that they need to pay us what's due plus any processing fees? Thank you for your attention to this matter." All right, Mark, what are we doing? What are your thoughts?

[07:00] Mark: For the most part, this is one of those areas where, as we work with groups around the country, you're going to the least costly method, which is typically ACH. So direct deposit. Sometimes there are fees that your bank charges. Those tend to be lower than the credit card fees, and in some cases there aren't fees for the ACH processing or the direct deposit. That's the best solution you've got.

From a "what can I do today" perspective, you could certainly talk to payers about their willingness to cover those transaction fees for credit card, check or other. But in the end, most of the responses we've gotten back from the payers is, "That's not our cost, that's yours. That is something your bank or your service industry is charging you, so not our problem. We're paying you under those contracts." For a small group wanting to get that covered, is it better to say, okay, we want a 5% raise in our payment rates, or go after a 3% processing fee? Maybe ask for both and take the 5% raise, if you look at the overall alternatives in the way that we negotiate or don't negotiate with our payers.

But the broader issue I would say we run up against that is related to this is the fact that a lot of practices don't have anyone specifically assigned to deal with credentialing, with your electronic processing, with keeping an eye on your PECOS enrollment. A lot of time passes between when you set up your practice, your NPI and all of those things, and when there's a need to actually get into PECOS, because it's behind the scenes and in the background. We've had a number of folks who have missed the notifications from PECOS that they need to do something. That could happen for a variety of reasons. It could be that you moved and didn't change your physical address, or you changed your email or contact information and you're no longer getting that notification.

So one of the things we do recommend you do routinely is double-check everything that is related to your reimbursement and how that's all set up. Check your credentialing with the payers. Obviously you need to re-credential with all the facilities that you work with. Check PECOS routinely. Make sure that all your information is up to date on all your websites. And make sure that if you've added new people to your practice, you get those individuals credentialed. Everything is slower right now, even in the age of AI and computers. There are still processes on the payer side of the equation, your bank, all those things, that require a human to approve and review things, and there are fewer and fewer of those working regularly for everybody. So stay ahead of all of that.

And again, go to the least costly processing, and check your speed. Checks may be the least costly, but actually checks are the least secure and things get lost. Even though transaction by transaction they might be a little bit cheaper, they are not typically cheaper overall because of the holes those create and the delays in mail, cutting checks, all of that makes things slower. So my recommendation is change everybody to ACH. That's typically what we do. We work hard to get that so that we can get the money as fast as we can with the least cost.

Then focus on your contract raises. Ask for a cost of living increase every year. It doesn't hurt to ask for the processing fees, but in reality we haven't seen much luck going after those processing fees. It is better to go after bumps in your payment rates. If you haven't touched your contracts for years, which a lot of folks have not, that's something that should be done routinely, annually, to ask for cost of living raises, to ask for those shifts in your payment rates to keep up with all the cost increases that you deal with. That should be a major checklist item for you. Add to that the credentialing, the double checks of your PECOS and your credentials within each of your facilities. That just has to be a focus of someone in the office to maintain all of those things.

Scott: Ray, do you have any questions?

[12:00] Ray: Mark, if I hear you correctly, you're saying that this is a big issue and it should be addressed at contract time, and addressed with whatever level of clout you have. Either be paid for the processing fee, or actually increase your rate of payment to compensate for that, if you can.

[13:00] Mark: Like I mentioned, asking for a processing fee is rarely something I have seen the payers do. So our typical approach is ask for a cost of living, and choose the least costly and most secure payment exchange that you can, because those fees are typically not fees charged by the insurance company. They typically respond with, "That is your cost of doing business, not mine." So you move to the least costly processing, and the most secure and fastest, which is typically direct deposit, ACH. Figure out which is the best for you with your bank, and then focus on getting the cost of living increase. Again, it doesn't hurt to ask for a processing fee, but more likely you're going to include that as one of your arguments in getting a cost of living bump in your reimbursement.

Finding out how your payers are paying you, and why credit card is the default

[14:00] Scott: All right, I've got a few questions for you. Let's say there's somebody out there listening who really hasn't paid attention to how everybody's getting paid or how the payments are coming in. What would you recommend to that provider, that urologist or even administrator? How do they go about finding out how they're paid, and who do they ask? Where does that fall?

[15:00] Mark: Typically your payment posting team or your revenue cycle management person is going to know which payers pay via credit card, via check, via ACH. That is mechanically where that hits your practice: whoever is in charge of payment posting. If you've got that outsourced, then you need to check with those individuals, or certainly go to your contacts to find out who's paying in which ways and how they're delivering that money to you. It's really that mechanical back end of whoever is monitoring the deposits going into the bank, be it your payment poster, your office manager who's opening the mail, or your revenue cycle management company.

Scott: And will these payers automatically switch you to whatever is easiest for them without you knowing? And which payers are more guilty, or have you noticed, of doing this?

[16:00] Mark: Typically the default way an insurance company will pay, if you do nothing when you're set up, is that credit card scan form, essentially. That's easy to transmit electronically with the EOBs. They don't have to physically cut a check or send things in the mail to you. If they go to your lockbox, because that's the electronic transfer into the lockbox, or if they're still mailing things, they'll still typically go to credit card processing as a default. So to get a check or to get ACH, you actually need to contact the payers and provide them with the appropriate information on how to send that money, bank numbers, those types of things. The payer doesn't have the ability to automatically set you up for ACH. That has to be your initiation, so they will default to the credit card. It's the easiest way for them to do it. It can be done automatically out of the system, it doesn't require anybody to sign checks or move checks around, and it's easily trackable, so that's the default. To get it another way, you typically have to contact the insurance company and figure out how to get that changed.

PECOS, CAQH and keeping credentialing current before there is a problem

[17:00] Scott: All right. And you mentioned PECOS and credentialing. If I were looking at it, and we were getting paid for the services by the payers, I would think that our credentialing and PECOS were all in order. But you're saying that may be happening, but there may still be an issue with PECOS and credentialing. Could you describe, for those who aren't familiar with PECOS, what that is? I always forget what it stands for.

[18:00] Mark: PECOS is the Provider Enrollment, Chain and Ownership System. It is the location that everyone goes to basically administer their NPI number, their national provider identification number, that was set up through Medicare in the beginning. You've probably got a couple of different organizations or entities within PECOS: an NPI-2 for your practice, maybe for locations that you have. Then of course you have your tax ID number for your entity, whatever entity you are actually working with that your NPI is assigned to. So those are the processing protocols: the NPI points to a TIN and has associated other NPIs and NPI-2s. All of that is administered under the PECOS website, with, of course, forms that need to be filled out and addressed for any changes that happen as you move through your career.

But at that base level, if you don't have your current address in PECOS, or you don't have the same email that you registered with, those are things that typically end up as problems. If you missed the three or four notifications from PECOS that you're expiring or something needs to be done, you're getting paid up until the time that expiration hits. And once you've got an expired NPI, or an expiration in there, or something that needs to be attested to, it takes a lot to get back in. So you're getting paid, and that's the same thing with credentialing. If you're getting paid right now, great, everything looks good now. But if you don't monitor those, waiting until you've got a problem is not a good way to go, because those problems are very difficult to fix.

And certainly as we look at people moving from practice to practice, and we look at the new hires that are out there, as people bring on APPs or other credentialed individuals within the practice, they bring them on and think, great, we've got them credentialed with the hospitals, we're good to go. Well, you've got to get people added to your contracts. They've got to be credentialed with the payers that you work with, and you need to do that as soon as you can because everybody processes things slowly. Then you need to double-check that you've got everything up to date. You're filling out your CAQH, which is another acronym I know but can never remember.

Scott: It is CAQH.

[21:00] Mark: You've got to make sure you're maintaining your credentials within CAQH, which is where a lot of the payers double-check credentialing year over year. You've got to make sure that you're credentialed with your hospitals and that you're staying on top of those. I think most people do pretty well with their facility credentialing, hospital privileges, ambulatory surgical center privileges, those types of things. But in the background, that CAQH and the PECOS, because you're getting paid, there's nothing wrong. Making sure that you're actually checking all of that before you have a problem is an essential part of maintaining your practice.

How often to renegotiate contracts, and where to get help

Scott: All right, two other questions. One has to do with contract negotiation. How often can you negotiate your contract?

[22:00] Mark: There's no real time limit on renegotiating a contract. I do recommend that yearly you attempt to ask for a cost of living increase. What we see most of the time is, "While I'm getting paid, I probably don't have any power to ask for a raise." So we see these evergreen contracts that renew year over year, and you're getting paid, and yeah, you're not getting paid as well as you would like, but you don't have any negotiating power. So those just sit in the drawer as something we might get to one day when every other fire in the office is out.

But we do see groups that typically ask for a cost of living every year. It's painful. It takes a while. Some do it every other year, some do it every third year, but there should be a regular cadence. Ultimately, whether you look at every other year, every three years or even every year, if you stagger the project so that you're dealing with your payers in different months, you can cut down the relative lift. Most of us try to take things on all at once, which makes the project bigger. But if you stagger it out throughout the year and keep working those payers as they go through, it's more manageable. You want to keep an eye on those things. You want to keep actively pinging those payers and pushing, because if you don't ask, nothing will happen. If you do ask, the worst is no. If you decide to push, then potentially the worst is you're out of that network. And as we've spoken about over the years, there are some payers that you really don't need, that it might be good to be out of their networks: they're slow paying, they're not paying very high, and you don't have that many primary care physicians involved. Going out of network with those is maybe not the worst idea in the world. So you have to prioritize as well as stagger, plan, and then execute.

[24:00] Scott: And what of this can PRS help with? If somebody's looking for help with their PECOS credentialing or contract negotiation, what do you recommend?

[25:00] Mark: We actually have a couple of groups that we've worked with over the years. This is a very involved process. We have helped folks deal with this, but the reality is there are better tools out there, and this is something where you want to find a very specialized group to work with. There are definitely groups that are very good within different states, and a number of individuals out there have found credentialing companies, or found individuals, if they're big enough, who are qualified and can leverage some of the tools in the marketplace. But it is a specialized solution. We do work with a couple of different groups in the marketplace and can certainly make those referrals, so reach out to us if that's something you're looking for. The other place I would recommend you consider contacting for credentialing services is your state medical society. They typically will have referrals. And then, of course, as we always say, talk to the village of urology: who else out there has a service that they're working with?

Sponsor and final thoughts

Scott: All right, let's go ahead and wrap up this episode. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prs for specials for our listening audience. Let's get some final thoughts. Mark, your final thoughts on all this?

[26:00] Mark: We're basically talking about a lot of things that are not under your direct control. We can't control the federal government and their inability to talk to one another, and we're definitely at the mercy of those folks as they navigate, or don't, the actual business of operating the government. So we have to react to what we've got. We know that Medicare is going to continue to pay. We know we have to switch, for Medicare telehealth, to ABNs or rescheduling. Those are the things we can control, and we need to do those things.

The same is true of credentialing and contracting. We can't control the outcomes of any negotiation, but we can control the initiation. Same with credentialing. There are a number of required updates that need to occur. So plan and put those things in place so that you can routinely and regularly manage everything you are going to have to deal with, and do it as a prospective process, not a reactive process. Those are my recommendations: build your protocols and procedures. It seems to be a theme across the board that protocols and procedures are essential parts of operating a medical practice. Ray, your final thoughts?

[28:00] Ray: All of you listening are probably urologists, or most of you are specialists, and you have seen the value of specialization and special knowledge, as we've all seen patients who have been mistreated by others with urological disease. The same thing applies to your practice. Specialty and specialization are important to get things done, and don't hesitate to use them in running your practice. Reach out when you need help on these specialized things: contracting, PECOS, et cetera. Get the help you need and do it right.

Scott: That is so true. I want to remind you that the Urology Advanced Coding and Reimbursement Seminars are coming up in Las Vegas in early December and in late January in New Orleans. Registration is open. You can go to the episode page for a link, or on the prsnetwork.com homepage there's a link right there. If you go to prsnetwork.com/262 for episode 262, there will be links to register for the Urology Advanced Coding and Reimbursement Seminar, where we have these discussions and you can get your questions answered in real time, and also hear what questions others are asking and share in that collective genius of the urology community. We really encourage you to join our live seminars. It's so beneficial.

The second thing I want to mention is the PRS Coding and Reimbursement Hub. We are adding more and more information to that this year as we go on. You can check it out at prsnetwork.com/urologyhub and see the various discussions we have on urology categories as well as individual products in the marketplace. We've got a lot of tools there as well, including an unlisted J code calculator, a kidney stone calculator and various quick reference guides. So we encourage you to check out the urology hub. That's all we have for today. Thank you all for listening. Take us out, Ray.

Ray: I guess we ought to add to the "happy coding" too. Happy business running? There's got to be something there. What's another good one? We could end it with happy coding...

Scott: And reimbursement.

Ray: Well, what we were talking about today isn't even reimbursement. Is there a broader term?

Scott: Maybe we switch on episode 275. Happy coding.

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