The Healthcare Business Management Association (HBMA) Government Relations Committee was fortunate to have the opportunity to meet with Centers for Medicare & Medicaid Services’ (CMS) directors and Senate Ways and Means Committee staff the day the proposed rule was published.
As I think we all have recognized, the most significant changes are intended to help small providers and practices. The proposed threshold increases in patient volume or dollars have, in effect, exempted many providers from participating in the Merit-based Incentive Payment System (MIPS). The ability to form virtual groups is also intended to allow maximum flexibility. Those are positive steps in recognition of the challenges MIPS presents.
In addition, many new options are proposed. For example, the ability to report 2018 quality measures via multiple methods as opposed to only claims, registry, etc. More measures have been added to increase successful reporting choices and opportunities for participating providers.
The Flip Side of the Coin
While these increased options and choices may sound good at first blush, the fact is that complexity and, therefore, cost for providers also increases. The thoughts and work behind the changes are well-intentioned. However, as author Dean Koontz said, “One man’s idea of perfect order is another man’s chaos.”
Some of the most basic informed decisions that providers must make are whether they want to work toward a bonus, remain revenue neutral, or accept a penalty. Accurately performing those projections based on specialty and practice-specific variables requires increasingly sophisticated software support and data analytics.
The unfortunate fact is that providers can make the best efforts to do everything right and still not be guaranteed of a bonus or even the amount of the bonus. Because the program must be revenue neutral, for every winner there must be a loser. One observation is the fact that “most providers will be forced to the middle”—and, in my opinion, that is the crux of the problem with MIPS.
How much money and work will providers invest when there is no return on that investment? We already know a very large percentage of eligible clinicians never participated in the Physician Quality Reporting System (PQRS). Are we really going to accept that none of those physicians or practices are providing quality care? Are we really going to accept that every physician or practice that does participate is providing the best quality care? I hope not, for that is a false belief that reporting data is the same as providing quality care.
While CMS’s intent to ensure all beneficiaries receive high quality care at a reasonable cost is a noble one, the methodology to achieve it is flawed. Adding myriad options that simply increase cost and complexity for physicians and their representatives, with no return on those investments, continues to whittle away at the precious time physicians have for their real job, which is patient care. That’s where quality happens, not in data-reporting.
Let’s help physicians get back to what they do best by removing the overwhelming administrative burdens. Then we will see real and meaningful quality.
The Centers for Medicare & Medicaid Services (CMS) operates a surveillance platform called the Fraud Prevention System (FPS) that analyzes Medicare claims across the full
EDITOR’S NOTE: Artificial intelligence was utilized for structural refinement and grammatical editing. All analyses, interpretations, and opinions expressed in this article are solely those of
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
