What Does CMS Stand for in Medical Billing?

Medical billing and revenue cycle management trends are evolving alongside technology. While there are solutions you can implement to streamline processes and improve financial stability, some medical billing considerations are not just nice to have — they are mandatory. 

Organizations like the Centers for Medicare & Medicaid Services (CMS), the largest payer for healthcare services, set the regulations, standards, and guidelines for billing services. The US Department of Health and Human Services (HHS) government agency administers major programs while collecting and analyzing data. They produce research reports aligning with their dedication to supporting better healthcare systems — the goal is to improve healthcare, wellness programs, and accessibility. Since over 160 million beneficiaries are enrolled in CMS health insurance programs, you must know how to work with the federal agency for successful medical billing outcomes.

History of CMS - Centers for Medicare 

President Lyndon B. Johnson signed Medicare into law as a medical care program in 1965. The Social Security Administration (SSA) initially administered the program under the Department of Health, Education, and Welfare. In 1977, the Health Care Financing Administration (HCFA) became the Centers for Medicare & Medicaid Services (CMS). 

The agency has expanded in scope and health coverage since President Johnson first established those initial medical care programs. With all the rate changes, exceptions, reporting, and other requirements over recent years, it’s more important than ever to consult with TempDev to determine appropriate provider solutions. You must ensure your practice is current on your regulatory requirements, and you’ll benefit from strategic advice to plan future initiatives. 

Key Functions of CMS in Medical Billing

CMS plays a pivotal role in medical billing by administering programs, determining compliance, developing IT programs, and setting reimbursement rates. These rates are based on factors like the type of service, how much it costs to provide it, and provider performance. Here are some of the main ways CMS influences medical billing:

• CMS sets policies and guidelines that impact coding and billing, prior authorization programs, electronic billing, and processes linked to the No Surprises Act. 

• Payment systems that influence value-based programs, bundled payments, the Medicare Quality Payment Program (QPP), etc. 

• Compliance considerations related to CMS include Medicare and Medicaid regulation audits, fraud prevention, consumer rights, and the Open Payments Program. 

CMS also collects and analyzes data on healthcare costs, utilization, and quality of care. This data influences policy decisions to improve programs and patient outcomes, all of which often impact medical billing. 

Centers for Medicare - Administration of Federal Healthcare Programs

CMS assists in administering major healthcare insurance programs in the United States, including Medicare, Medicare Advantage, Medicaid, the Children's Health Insurance Program (CHIP), and the Health Insurance Marketplace. 

This agency's primary role is ensuring access to healthcare services. However, it also manages budgets, sets eligibility criteria, and coordinates the implementation of these programs with state governments. 

Centers for Medicare - Reimbursement and Regulatory Functions

The Centers for Medicare (CMS) administers the following:  

CMS administers healthcare programs and determines whether healthcare providers and care facilities have successfully implemented healthcare IT programs and are compliant. They can set reimbursement rates for healthcare providers based on their use of healthcare IT programs as outlined in MACRA & HITECH.  

TempDev offers the support and solutions to ensure your medical organization operates at peak efficiency. In recent years, CMS policy changes have been implemented to reduce the healthcare system's cost and complexity. These changes also aim to make it easier for providers to comply with the various regulations that Congress implements. Work with TempDev to ensure you're up-to-date concerning the latest CMS changes and get support with any pressing healthcare challenges. 

Medicare Advantage

If you are an organization that participates in Medicare Advantage, your star rating significantly affects reimbursement and patient enrollments. Being a Medicare Advantage participant also means submitting quality reporting on relevant data. TempDev can help you optimize your NextGen EHR to improve your quality scores and remain compliant. Here are some considerations to improve reimbursement and patient enrollment rates. 

How Star Ratings Influence Reimbursement

Higher star ratings mean increased reimbursement rates for Medicare Advantage plans. The CMA uses a 5-star system to evaluate Medicare Advantage (MA) plans. If you receive 4 or 5 stars, you can be eligible for quality bonus payments. These additional payments, paid by CMS, reward performance and high-quality care. While no significant changes were made in 2025, staying in the know will help maximize your rating and potential earnings. TempDev can help you optimize your NextGen EHR and take a more holistic approach to Medicare star rating quality scores.

The Impact of Star Ratings on Patient Enrollment

Financial incentives aren't the only advantage of higher Medicare program star ratings—increased patient enrollment is another benefit. Improved member retention is also a consideration, as members are more likely to stay with a plan that meets or exceeds their expectations. So, as you increase your star rating, you can see significant increases in health plan enrollment rates and decreases in health plan disenrollment. 

Office of the National Coordinator - ONC-Affiliated Agency

The Office of the National Coordinator for Health Information Technology (ONC) works with CMS. The ONC approves certified healthcare IT systems, essential for regulatory, security, and privacy regulations under the Cures Act, MACRA, HITECH, and HIPAA. Healthcare IT has increased in importance as more hospitals and healthcare organizations transition to electronic healthcare records (EHRs) and electronic medical records (EMRs).  

ONC has been instrumental in spearheading the successful adoption and implementation of EHRs by doctors and medical staff at hospitals and medical facilities across the US. According to the ONC, 85% of hospitals have electronically queried or found patient health information through various methods, including their EHRs. However, barriers exist, most of which TempDev can directly assist with. 

Recent Updates and Changes in CMS Policies

In 2025, CMS finalized rules that have impacted medical billing, including updates to telehealth policies, prior authorization rules, Medicare Advantage and Part D programs, and physician fee schedules. 

For example, in 2025, the conversion factor used to calculate scheduled Medicare payments was reduced to 2.83%. Another area to consider is overpayment standards, as changes link overpayment to False Claims Act statutory requirements. Medicare Parts A and B providers will not have six months to investigate and quantify payments. 

Read more: What is Prior Authorization in Medical Billing?

How TempDev Can Help with CMS Regulatory Trends

TempDev’s team of NextGen & CMS experts support you in meeting regulatory requirements to succeed in revenue cycle management and quality initiatives. TempDev supports your need for custom automation, configuration, dashboards, remote patient monitoring, telehealth, and workflow redesign for CMS. 

Navigating CMS Changes 

It’s often challenging to keep up with the transformations in the healthcare industry, so TempDev’s team of experts is standing by to consult with you and help you better understand the policy changes. Knowing how these changes affect revenue and compliance encourages a more successful practice. 

TempDev will work with you to satisfy CMS regulations and requirements so that you can focus on patient care. Your goal continues to be to protect your staff, doctors, and patients while providing quality care, affordable care and healthcare pricing, and flexible care options. You can do just that by staying educated and having the right systems in place. TempDev offers the tools and support you need to get the most out of your NextGen system.

Improving Star Ratings with NextGen EHR

If you want to improve star ratings, start with your EHR system. Data integrity and accuracy, as well as seamless integration, are crucial. For example, you'll want to take a data-driven approach, focusing on maximizing your EHR's capabilities. Use quality dashboards to identify care gaps, improve interoperability, and automate reporting. You'll also want to promote population health management using your EHR, enhance patient experiences, and improve access to care.

Monitor performance metrics to take action — and track the top medical billing KPIs. TempDev consultants and developers will help you develop and implement a holistic plan to improve your star rating. TempDev can help optimize EHR systems to enhance quality scores and achieve better star ratings. Its innovative tools, like the latest NextGen EHR Operations BI Dashboard, can also optimize workflows, track performance metrics, conduct billing audits, and more. 

Identifying Weaknesses in Revenue Cycle Management

CMS plays a role in several everyday processes and considerations, and many physicians focus on how CMS influences healthcare revenue. While certain variables, such as rates and quality measures, are outside your control, you can make changes to enhance revenue cycle management practices. 

TempDev will help you pinpoint weaknesses so that you can take action to improve workflows and boost revenue. Use TempDev's Revenue Cycle Dashboard NextGen EPM Report and NextGen dashboards to identify issues and follow trends. If you're trying to improve revenue cycle workflows, check out TempDev's TempBill. 

Contact us here to get the help you need with the Centers for Medicare & Medicaid Services requirements this year and beyond. Ask about our services and innovative solutions to help you address CMS concerns and those involving revenue cycles, staff augmentation, and more. Call us at 888.TEMP.DEV today!