{"id":828,"date":"2024-12-18T07:47:10","date_gmt":"2024-12-18T07:47:10","guid":{"rendered":"https:\/\/atlanticrcm.com\/blog\/?p=828"},"modified":"2024-12-18T07:46:33","modified_gmt":"2024-12-18T07:46:33","slug":"medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm","status":"publish","type":"post","link":"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/","title":{"rendered":"Medicare Advantage 2025 Updates: What Are The Changes and How Will They Impact RCM"},"content":{"rendered":"<p><strong>33.1 Million<\/strong>\u2013That\u2019s how many participants are enrolled in the Medicare Advantage (MA) program in 2024.<\/p>\n<p>There has been a significant penetration and exponentially increasing enrollment in the MA program, according to a <a href=\"https:\/\/atiadvisory.com\/resources\/wp-content\/uploads\/2024\/03\/2024-Medicare-Advantage-Enrollment-Databook.pdf\">report by ATI Advisory<\/a>, between 2023 and 2024 alone, 2.2 Million participants enrolled in this program, which is a 7.1% Y-O-Y growth. Today, 50.2% of Medicare beneficiaries are enrolled in MA plans, compared to 47.9% in 2023.<\/p>\n<p>The Centres for Medicare and Medicaid Services (CMS) has proposed many updates to the MA program in 2025. The main objective of these policy changes is to improve care quality, equity, and efficiency.<\/p>\n<p>With such an incredible penetration and a huge participant base, these changes will impact patients and healthcare providers and how their revenue cycle is managed. If you are a healthcare organization, an RCM professional, or an RCM solutions provider, this blog will help you stay updated and proactively adapt to these changes.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-large wp-image-830\" src=\"https:\/\/atlanticrcm.com\/blog\/wp-content\/uploads\/2024\/12\/Recent-Medicare-Beneficiary-Trends-1024x768.png\" alt=\"Recent Medicare Beneficiary Trends\" width=\"1024\" height=\"768\" srcset=\"https:\/\/atlanticrcm.com\/blog\/wp-content\/uploads\/2024\/12\/Recent-Medicare-Beneficiary-Trends-1024x768.png 1024w, https:\/\/atlanticrcm.com\/blog\/wp-content\/uploads\/2024\/12\/Recent-Medicare-Beneficiary-Trends-300x225.png 300w, https:\/\/atlanticrcm.com\/blog\/wp-content\/uploads\/2024\/12\/Recent-Medicare-Beneficiary-Trends-768x576.png 768w, https:\/\/atlanticrcm.com\/blog\/wp-content\/uploads\/2024\/12\/Recent-Medicare-Beneficiary-Trends-1536x1152.png 1536w, https:\/\/atlanticrcm.com\/blog\/wp-content\/uploads\/2024\/12\/Recent-Medicare-Beneficiary-Trends.png 1600w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/p>\n<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_69_1 counter-hierarchy ez-toc-counter ez-toc-grey ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In this Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#What_are_the_Big_MA_Changes_in_2025\" title=\"What are the Big MA Changes in 2025?\">What are the Big MA Changes in 2025?<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#1_Premium_Adjustments\" title=\"1. Premium Adjustments\">1. Premium Adjustments<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#2_Risk_Adjustment_Models\" title=\"2. Risk Adjustment Models\">2. Risk Adjustment Models<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#3_Overhauling_the_Star_Ratings\" title=\"3. Overhauling the Star Ratings\">3. Overhauling the Star Ratings<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#4_Streamlining_Prior_Authorizations\" title=\"4. Streamlining Prior Authorizations\">4. Streamlining Prior Authorizations<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#How_These_Changes_Impact_RCM_Teams\" title=\"How These Changes Impact RCM Teams\">How These Changes Impact RCM Teams<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-7\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#1_Billing_Practices\" title=\"1. Billing Practices\">1. Billing Practices<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-8\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#2_Claim_Processing\" title=\"2. Claim Processing\">2. Claim Processing<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-9\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#3_Reimbursement_Strategies\" title=\"3. Reimbursement Strategies\">3. Reimbursement Strategies<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-10\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#How_can_RCM_Teams_Prepare_for_2025\" title=\"How can RCM Teams Prepare for 2025\">How can RCM Teams Prepare for 2025<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-11\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#1_Leverage_Technology\" title=\"1. Leverage Technology\">1. Leverage Technology<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-12\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#2_Train_Your_Employees\" title=\"2. Train Your Employees\">2. Train Your Employees<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-13\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#3_Improve_Team_Collaboration\" title=\"3. Improve Team Collaboration\">3. Improve Team Collaboration<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-14\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#4_Stay_Informed_About_the_Regulatory_Changes\" title=\"4. Stay Informed About the Regulatory Changes\">4. Stay Informed About the Regulatory Changes<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-15\" href=\"https:\/\/atlanticrcm.com\/blog\/medicare-advantage-2025-updates-what-are-the-changes-and-how-will-they-impact-rcm\/#Let_Atlantic_RCM_Help_You_Navigate_These_Changes\" title=\"Let Atlantic RCM Help You Navigate These Changes\">Let Atlantic RCM Help You Navigate These Changes<\/a><\/li><\/ul><\/nav><\/div>\n<h2><span class=\"ez-toc-section\" id=\"What_are_the_Big_MA_Changes_in_2025\"><\/span><strong>What are the Big MA Changes in 2025?<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>The 2025 updates focus on 3 main areas\u2013premium adjustments, risk adjustment models, and the Medicare Advantage Star Rating Systems. These shifts highlight CMS\u2019s commitment to implementing value-based care and equity.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"1_Premium_Adjustments\"><\/span><strong>1. Premium Adjustments<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>From 2025, CMS is adjusting the MA premiums, which is one of the most significant changes. How much is changing\u2013the specifics vary between various regions and demographics. But the main objective behind this adjustment is that the providers serving the vulnerable population might see that their reimbursement is tied to patient income level and plan choices.<\/p>\n<p>This means that the billing team has to proactively ensure that all patient demographic information is up-to-date, especially patients qualifying for additional benefits or subsidies. If these details are missed out, it could result in discrepancy in reimbursements and revenue.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"2_Risk_Adjustment_Models\"><\/span><strong>2. Risk Adjustment Models<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>CMS has incorporated social detriments of health (SODH) along with the chronic illness severity metrics. This change is aimed at meeting the patient needs and the associated costs more accurately.<\/p>\n<p>For example, a patient in a medically underserved area might have\u00a0 SODH factors\u2013like housing instability or food security\u2013that increase the complexities. Healthcare providers must accurately code these SODH factors and ensure that they are fairly compensated for the care they provide.<\/p>\n<p>Any documentation errors or gaps could lead to inaccurate coding that could result in missed revenue or, worse, penalties.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"3_Overhauling_the_Star_Ratings\"><\/span><strong>3. Overhauling the Star Ratings<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>For MA programs, star ratings play a crucial role in reimbursements. Starting in 2025, CMS will emphasise patient outcomes and equity metrics more, aligning reimbursements with quality care.<\/p>\n<p>For example, a plan with a lower star rating might get a lower reimbursement, and the beneficiaries might opt for competitors. The RCM team must collaborate with clinical teams and ensure that the quality measures are tracked, documented, and reported accurately.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"4_Streamlining_Prior_Authorizations\"><\/span><strong>4. Streamlining Prior Authorizations<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>Traditionally, prior authorizations increase the administrative burden, creating issues that delay care and revenue cycles. In 2025, CMS is planning to streamline the prior authorization processes by leveraging automation and reducing manual errors.<\/p>\n<p>While this change will improve efficiency, the RCM teams must adapt their workflows and integrate new technologies quickly.<\/p>\n<h2><span class=\"ez-toc-section\" id=\"How_These_Changes_Impact_RCM_Teams\"><\/span><strong>How These Changes Impact RCM Teams<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>The overall objective of the 2025 CMS updates is value-based care, where reimbursements are linked directly to outcomes, equity, and efficiency. Let\u2019s look at how these changes affect <a class=\"wpil_keyword_link\" href=\"https:\/\/atlanticrcm.com\/revenue-cycle-management.php\"   title=\"Revenue Cycle Management\" data-wpil-keyword-link=\"linked\">Revenue Cycle Management<\/a>.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"1_Billing_Practices\"><\/span><strong>1. Billing Practices<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>With adjustments in premiums and risk models, billing practices need to be more accurate than ever. In order to maximize reimbursements, accurate demographic data collection and coding have become strategic necessities.<\/p>\n<p><strong>Action Point: <\/strong>Conduct regular billing audits to ensure all patient data is accurate and up-to-date.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"2_Claim_Processing\"><\/span><strong>2. Claim Processing<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>Since SODH is included in the risk adjustment model, the RCM team must focus on capturing and documenting every aspect of patient care. The billing team must collaborate with the clinical team to ensure that the claim accurately reflects the complexity of the care provided.<\/p>\n<p><strong>Action Point: <\/strong>Invest in an integrated claim processing platform, like <a href=\"https:\/\/eclaimstatus.com\/\">eClaim Status<\/a>, that can simplify coding and documentation.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"3_Reimbursement_Strategies\"><\/span><strong>3. Reimbursement Strategies<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>Star Ratings will play a more important role in determining the reimbursement levels in 2025. Low ratings could result in penalties, while higher ratings could increase revenue opportunities.<\/p>\n<p><strong>Action Point:<\/strong> Work proactively with clinical teams to track performance metrics in real time and address any errors and gaps in documentation or care delivery.<\/p>\n<h2><span class=\"ez-toc-section\" id=\"How_can_RCM_Teams_Prepare_for_2025\"><\/span><strong>How can RCM Teams Prepare for 2025<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>Managing and proactively adapting to these changes requires a strategic approach. Here\u2019s what Atlantic RCM recommends to help you stay ahead:<\/p>\n<h3><span class=\"ez-toc-section\" id=\"1_Leverage_Technology\"><\/span><strong>1. Leverage Technology<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>With the implementation of the new CMS rules, billing and coding will become even more complex. Tools like AI-driven analytics, automated claims processing, and real-time performance dashboards can be utilized to make the processes faster and more accurate.<\/p>\n<p>Look for platforms that can integrate coding, documentation, and claims management into a single system.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"2_Train_Your_Employees\"><\/span><strong>2. Train Your Employees<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>Invest in frequent training to educate your employees and help them master the new coding standards and adjustment criteria.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"3_Improve_Team_Collaboration\"><\/span><strong>3. Improve Team Collaboration<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>These policy changes require a high level of coordination and collaboration between your billing and clinical teams. Clear communication between them ensures that the care, outcomes, and equity metrics are accurately and elaborately documented.<\/p>\n<h3><span class=\"ez-toc-section\" id=\"4_Stay_Informed_About_the_Regulatory_Changes\"><\/span><strong>4. Stay Informed About the Regulatory Changes<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h3>\n<p>Keep yourself updated about the CMS announcements and other regulatory changes to avoid financial loss. This helps you in aligning your processes with the latest guidelines.<\/p>\n<h2><span class=\"ez-toc-section\" id=\"Let_Atlantic_RCM_Help_You_Navigate_These_Changes\"><\/span><strong>Let Atlantic RCM Help You Navigate These Changes<\/strong><span class=\"ez-toc-section-end\"><\/span><\/h2>\n<p>The 2025 Medicare Advantage updates might seem overwhelming at the beginning, but with the right approach, these policy changes can improve equity, efficiency, and revenue potential. By investing in the right technology, training, and strategic planning, we can help healthcare organizations adapt to these changes.<\/p>\n<p>With over a decade of experience in healthcare revenue cycle management, Atlantic RCM can help you improve your financial health amidst these changing times.<\/p>\n<p>Contact <a href=\"https:\/\/atlanticrcm.com\/contact-us.php\">Atlantic RCM<\/a> today to future-proof your RCM strategy.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>33.1 Million\u2013That\u2019s how many participants are enrolled in the Medicare Advantage (MA) program in 2024. There has been a significant penetration and exponentially increasing enrollment in<span class=\"excerpt-hellip\"> [\u2026]<\/span><\/p>\n","protected":false},"author":1,"featured_media":829,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5],"tags":[],"class_list":["post-828","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-blogs"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.8 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Medicare Advantage Updates 2025 And Their Impacts on RCM - Atlantic RCM<\/title>\n<meta name=\"description\" content=\"Understand the major policy changes to Medicare Advantage Plans in 2025. 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