Transforming Revenue Cycle Management in

1. Evolving Dynamics in RCM

Value-Based Care (VBC) Models

The push for value-based care (VBC) in the U.S. is led primarily by the federal government, with the Centers for Medicare & Medicaid Services (CMS) setting ambitious goals to transition all Medicare payments to value-based models by 2030. Healthcare providers, especially larger systems and accountable care organizations (ACOs), are increasingly participating to improve outcomes and share in cost savings. Patients, too, are influencing this shift through a growing demand for more personalized, coordinated, and outcome-driven care.

The shift from fee-for-service to value-based care is compelling providers to focus on patient outcomes rather than service volume. Under VBC, providers face greater financial risk and reward, depending on their ability to improve patient outcomes and control costs. This model requires significant investment in data analytics, care coordination, and preventive care strategies. While larger health systems are better equipped to handle these changes, smaller practices often struggle with administrative and technological demands. Despite these challenges, VBC aims to enhance care quality and patient satisfaction while reducing unnecessary spending, aligning financial incentives with long-term health outcomes. To enable these transitions, healthcare providers are looking for off-the-shelf solutions that can kickstart their projects with embedded data analytics, improved clinical documentation, and a more integrated approach to care delivery.

Regulatory Changes

The Centers for Medicare & Medicaid Services (CMS) have introduced updates to the 2025 Fee Schedule, impacting reimbursement rates and billing codes. These changing guidelines are significantly impacting RCM by introducing regulatory and reimbursement changes that require providers to adapt quickly. Key updates include the unbundling of care management billing codes for rural health clinics (RHCs) and Federally Qualified Health Centers (FQHCs), eliminating the previously used G0511 code, which increases billing complexity and demands more detailed coding. CMS is also removing productivity standards for RHCs, altering financial planning assumptions, and implementing reforms to streamline the prior authorization process. Additionally, the discontinuation of four Medicare payment models will force participating providers to revise their RCM strategies. Together, these changes demand enhanced compliance, better financial forecasting, and updated billing workflows to maintain revenue integrity and operational efficiency.

Technological Advancements

Technology enhancements are transforming RCM by streamlining operations, improving accuracy, and aligning financial processes with clinical care. Modern EHRs and EMRs have evolved into integrated, cloud-based platforms with built-in billing tools and real-time data capture, enhancing coding precision and speeding up claims. Automation and AI reduce manual errors and accelerate workflows, while predictive analytics help identify revenue risks and optimize financial performance. Crucially, improved interoperability—driven by mandates like the 21st Century Cures Act—is enabling seamless data exchange between providers, payers, and patients, reducing delays and errors. Together, these advancements are making RCM more efficient, transparent, and patient-centered.