There are always unknowns about what the year ahead holds for healthcare providers, especially in years when there is a change in presidential leadership and a new administration. However, overarching federal changes and policy shifts are typically slow to implement, which means our current increasingly complex regulatory environment and associated provider burdens are likely to continue, especially in the areas of compliance, reimbursement, and patient care.

One of the best ways to mitigate the impact and stay ahead of existing and upcoming regulations is to be prepared. Without adequate preparation, providers could pay the price operationally and financially.

Current regulatory landscape

According to a recent analysis by HFMA and its policy experts, there are four significant bipartisan policy changes that are possible, if not likely, in the new year. These are “site-neutral payments, prior authorization, the 340B Drug Pricing Program, and mergers and acquisitions (M&A).” These regulations are meant to save money, reduce administrative burdens, lower the cost of care, protect patients, and improve outcomes. However, they may also present substantial challenges and extra work for providers.

One notable upcoming regulation is the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). This rule, which is set to begin in 2026, will require Medicare Advantage plans to return prior authorization decisions for urgent requests within three days and within seven days for other requests. Providers will have work to do to comply with the new rule as well: “Eligible hospitals and critical access hospitals that participate in the Medicare Promoting Interoperability Program, as well as MIPS eligible clinicians that participate in the MIPS Promoting Interoperability performance category” will have to “report two new electronic prior authorization measures for the CY 2027 performance period/2029 MIPS payment year or the CY 2027 EHR reporting period.”

These are just a small sampling of the many regulations and rules currently planned or expected to change in 2025. While the end goal may be reducing costs and improving outcomes, the initial administrative and financial impact on providers could be significant. The bottom line is that providers must do all they can now to be prepared.

Key strategies to stay ahead of regulatory changes

There are multiple opportunities providers can implement to help strengthen their operations and optimize their revenue cycle amidst these challenges. These include utilizing advanced technology like robotic process automation (RPA) and artificial intelligence (AI) to reduce manual, error-prone processes. For example, leveraging RPA and AI for patient access, clinical documentation improvement (CDI), and claims coding can improve eligibility and coverage verification, documentation compliance, and coding accuracy while also reducing denials and write-offs.

Investing in staff education is another vital element for achieving and maintaining compliance with new and changing regulations. Several professional organizations offer this type of training, as well as certifications. Making this investment will pay dividends when it comes to avoiding stiff penalties for regulatory noncompliance.

Another opportunity is using data analytics to identify problematic trends, such as timely filing issues or specific payer-related denial patterns, so they can be proactively addressed before they have a chance to impact revenue. Analytics, accompanied by regular audits, can also help providers assess regulatory adherence and pinpoint areas needing improvement.

Partnering with industry revenue cycle and compliance experts is another excellent option. Conifer Health has decades of experience, along with a dedicated team of compliance experts, enabling it to provide strategic guidance to providers nationwide. Conifer’s experience and proactive approach help healthcare organizations stay ahead of regulatory changes while mitigating risk and maintaining financial stability.

The Bottom Line

Even without regulatory changes, providers face increasingly complex challenges in 2025. For one, the Medicare Physician Fee Schedule will reduce average payment rates by 2.93% compared to 2024. At the same time, Medicare telehealth services are scheduled to return to their pre-COVID limitations and reimbursement rates, although work is ongoing to retain or expand services in certain instances.

When added to the many unknowns around the new administration and the already-planned regulatory changes, providers will need all the help they can get in the new year. Partnering with Conifer Health is an excellent opportunity to obtain the support they need to navigate these challenging times.