The fourth quarter started last Thursday. For most practices and every surgery center it's the busiest billing stretch of the year, and it arrives on the same calendar every time, which means it can be planned for. This edition is the plan: what the rush actually does to a billing operation, the moves that keep it from becoming January's problem, and three changes to codes and coverage that land inside the quarter.
THE FIELD: THE Q4 RUSH
Two things: what the rush does, and what to do about it.
What the rush actually does.
Patients who've met their deductibles push to get every procedure they've been postponing done before the plan year resets. Case volume climbs, claims climb with it, and every hour of billing capacity goes to getting the new work out clean. The thing that gives is follow-up: the September claims still pending, the denials from last month, the aged balances. Nobody decides to neglect them. The rush simply consumes the hours that used to work them.
Two more things happen at the same time. Payer offices close for long weekends around Thanksgiving and Christmas, so anything that stalls into the holidays finishes in February, and some practices slow down rather than speed up because providers take time off.
What it means for you: the rush is temporary, so most operations shouldn't hire for it. The volume evens out in January. What they should do is decide, in October, what gets deferred if capacity runs short, so the deferral happens by decision and not by accident.
The prep list.
Five moves, in order of urgency. Work the aged AR down now, because every old balance still open in November competes with new claims for the same hands. Write down a denial-touch deadline, the maximum number of days a denial can sit untouched, rush or not.
Pre-verify authorization requirements for your highest-volume procedures, payer by payer, so the surge doesn't generate a matching wave of preventable denials. Start any credentialing that needs to finish by January this week, since the holiday closures add weeks to applications already measured in weeks. And reserve one hour a week for follow-up that the rush can't touch, on the calendar, owned by a name.
What it means for you: the centers that come out of Q4 clean describe it as busy. The ones that don't describe January as recovery. The difference is decided in the next two weeks.
For surgery centers, the capacity and Q4 planning sections of our ASC guide go deeper on all five. It's free, at thepracticeoperator.co/asc-billing.
THE WIRE
Three things on the calendar this quarter, and what each one means for your practice.
The new diagnosis codes took effect last Thursday.
The 2027 ICD-10-CM update went live October 1: 190 new diagnosis codes, 30 deleted, and 4 revised. Deleted codes are invalid for any encounter from that date forward, and claims carrying them reject on arrival. The pattern this year is specificity: several familiar diagnoses split into more detailed codes, plantar fasciitis by foot being one example that touches pain and podiatry practices directly.
Why it matters: check your most-used diagnoses against the published conversion table, update the favorites and superbill templates in your EHR, and watch the first two weeks of October rejections for anything coded before the cutover.
A large share of Medicare Advantage patients will change plans for January.
Insurers are leaving unprofitable counties for 2027 at an accelerating pace. Roughly 2.6 million people lost their Medicare Advantage plan for 2026, and one major carrier alone has told investors its 2027 exits will affect about 600,000 members. Non-renewal notices are going out now. Annual enrollment runs October 15 through December 7, and marketplace enrollment opens November 1.
Why it matters: a meaningful share of your Medicare patients will walk in after New Year's with coverage you've never seen. Two things now: confirm you're enrolled with the plans gaining members in your county, and add the plan-change question to every appointment reminder from here to December.
The 2027 CPT set is out, and it takes effect January 1.
The AMA released next year's procedure codes with 453 editorial changes: 299 new codes, 74 revisions, and 80 deletions. The headline change replaces the global maternity bundle with phase-specific codes, and there are notable updates to hernia repair, prostate biopsy, biofeedback, radiology, and sleep medicine. Deleted codes are invalid for dates of service on or after January 1, and payment values arrive with the final fee schedule in early November.
Why it matters: this is the quarter to find out which of your procedures changed, before the first January claims go out under the old codes and come back as rejections.
“Is It Normal?”
One real question from a practice operator, answered straight. Identities stay out of it.
“Our total A/R goes up every fourth quarter, even though we're collecting more than we ever have. Is something wrong?”
Normal, and worth understanding precisely, because the total is the wrong number to watch in a busy quarter.
Accounts receivable is everything you've billed and haven't yet collected. When volume jumps, the amount you've billed jumps with it, and the total grows for the best possible reason: more work went out the door. A rising total in Q4 is what success looks like on that particular report.
What matters is the shape. Break the total into aging buckets and look at each as a share of the whole. In a healthy rush, the 0 to 30 day bucket swells, because it's full of fresh claims, and the over-90 share holds steady or falls. That's an operation absorbing volume without losing its grip on follow-up.
The warning sign is the over-90 share rising during the rush. That means the follow-up is losing to the volume, and the aged money is growing faster than the new money. It's the exact thing the reserved weekly hour in the prep list above exists to prevent.
One check, thirty seconds: your over-90 percentage today against what it was in September. If it's flat, the rising total is fine. If it's climbing, the total is hiding a problem.
Have one of these questions yourself, the kind you've been staring at alone? Hit reply. Every edition answers one, and nobody will know it was yours.
Talk soon,
Dr. Tarek Shahbandar
President, Expert Medical Billing · Practicing physician, 25+ years
NEXT EDITION: Open enrollment, and the patients who'll walk in with new coverage in January. What to set up now.