6 Key Healthcare Policy Changes to Know for 2025 and Beyond

1. Payment & Reimbursement Changes

For Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) site-neutral payments, the Centers for Medicare & Medicaid Services (CMS) raised OPPS rates by ~2.9 percent, but many off‑campus outpatient services now get reimbursed at lower ASC rates, impacting hospital revenue streams. Providers should verify correct site-of-service coding and cost reporting.

For the Physician Fee Schedule (PFS), the Medicare conversion factor dropped by ~2.2 percent as of Jan. 1, 2025. New billing codes were added for chronic care management and non-face-to-face services like e-visits and virtual check-ins.

For stem cell/organ acquisition, as of April 7, 2025, acquisition costs for stem-cell therapies in Medicare Advantage (MA) inpatient claims are no longer eligible for pass-through payment.

2. Expanded Telehealth & Behavioral Health Coverage

Telehealth flexibility: reimbursement at non-facility rates continues through at least Sept. 30, 2025, with no geographic restrictions (e.g. home visits, rural/non-rural alike).

Expanded provider eligibility: physical, occupational, and speech therapists are added to Medicare telehealth‑eligible providers. Audio‑only (telephone) service qualifies for behavioral health when video is not viable.

Behavioral health billing: peer support specialists, licensed counselors, licensed marriage and family therapists (LMFTs), and Federally Qualified Health Center/Rural Health Clinic (FQHC/RHC) behavioral visits are reimbursable, including integrated care codes under PFS.

3. Audit & Compliance

Artificial intelligence (AI)-driven audits: Medicare auditors increasingly use AI/data analytics in 2025 to flag anomalous billing and inconsistency. Providers must ensure detailed documentation, especially for telehealth and high-cost services.

Managed-care risk coding scrutiny: focused audits centering on MA coding accuracy and risk-adjustment practices mean stringent documentation for providers working with MA plans.

Probe-and-educate audits: more precise Targeted Probe-and-Educate (TPE) audits targeting outpatient therapy, evaluation and management (E&M) visits, and transitions of care are expected, highlighting the need for accurate coding workflows.

4. Enrollment & Administrative Streamlining

Medicaid Provider Enrollment Streamlining Act: this bipartisan bill aims to simplify provider enrollment by sharing credentialing across states and aligning Medicaid and Medicare enrollment records, reducing duplication and administrative burden.

5. Medicaid Cuts & Provider Tax Changes

Medicaid funding cuts of $900 billion+ over 10 years are to include:

• Reduced provider tax cap (down to 3.5 percent by 2031) impacting state Medicaid finances;
• Limits on state‑directed payments above Medicare rates to providers, affecting supplemental Medicaid payments; and
• For rural hospitals, the $50 billion rural transformation fund only offsets ~37 percent of projected losses.

6. Provider Choice & Legal Impacts

Under the U.S. Supreme Court ruling (June 26, 2025) in Medina v. Planned Parenthood, Medicaid beneficiaries no longer have a federally enforceable “free choice of provider” right. States may restrict Medicaid payments to specific providers – for example, excluding clinics that offer abortion care – even if federal law previously safeguarded choice. This has serious implications for providers in affected states.

What Providers Should Do Now:

• Review site-of-service codes, and implement new telehealth and behavioral health CPT/E&M codes. Rigorous documentation is essential.
• Ensure documentation aligns with non-facility standards and includes proper audio-only justification, if applicable.
• Strengthen coding workflows in areas flagged for AI review (e.g. chronic care, therapy, high-utilization services). Offer staff training.
• Stay informed about state-specific decisions that may exclude provider types or cut funding (e.g. Planned Parenthood, abortion services).
• Review revenue projections given Medicaid cuts and 340B repayment accelerations affecting safety-net and rural hospitals

Healthcare providers in 2025 and beyond face a shifting policy landscape. Stay tuned!