Allow me to preface this article by noting that I am not Dr. Hirsch – he’s traveling and asked me to fill in for him today. My name is Dr. Clarissa Barnes, and I am an internist, current President of the American College of Physician Advisors, and the Chief Medical Officer for South Dakota Medicaid.
Medicare gets a lot of attention from physician advisors – which is partially historic, owing to the conditions of participation that originated the utilization review (UR) committee and the administrative functions that gave rise to the physician advisor, and partially practical, given the large number of hospitalized patients with Medicare or Medicare Advantage (MA) plans. However, as any pediatric physician advisor will tell you, Medicaid is a significant player in the payor space.
Nationally, Medicaid is the largest payor for children and young adults. Medicaid covers 41 percent of all births and is the largest payor of long-term services and supports (LTSS), as well as the largest single payor of services to treat substance use disorders and services to prevent and treat HIV. I will admit that during my years as a physician advisor, I was relatively Medicare/Medicare Advantage focused. There was always plenty of work to do if you just focused on UR functions for the Medicare population. That being said, you’ll be selling yourself and your organization short if you’re not aware of the opportunities you have with Medicaid.
To that end, I wanted to make you aware of the Ensuring Access to Medicaid Services Final Rule (CMS-2442-F). This one is easy to overlook, especially if you’re inpatient-focused. However, hidden in it are a couple items to note. This rule requires states to publish fee-for-service (FFS) Medicaid fee schedule payment rates on a publicly available website. Even if your state is heavily managed, you still likely have some FFS portions, and knowing these rates will give you insight into what they’re expecting for their managed partners.
Additionally, FFS Medicaid will have to compare their primary care, OB/GYN, and outpatient mental health/substance use disorder services to Medicare rates and publish it every two years. And beyond the superficial renaming of the Medical Care Advisory Committees to the Medicaid Advisory Committees (MAC), they are establishing Beneficiary Advisory Councils (BACs) for every state, each comprised of beneficiaries/families/and/or caregivers. Information about MAC/BAC activities is going to be publicly available, including bylaws, agendas, minutes, membership lists, and meeting schedules – and at least two MAC meetings per year are going to be open to the public, with a public comment period.
The difference between trying to influence something at the federal level versus the state level is huge. This transparency is only going to make it easier for you to get access to state decision-makers. The best-case scenario is this: see if you can get on your state MAC. At the very least, start showing up for those twice-a-year public meetings.
For all the physician advisors reading this, I also wanted to remind everyone that the American College of Physician Advisors (ACPA) mentorship program, Cultivating Physician Advisor Leaders (CPAL), is currently open for applications for mentors and mentees at acpadvisors.org, through the end of this week.
You do have to be an ACPA member, but otherwise the program is free.
In the CY 2026 OPPS/ASC Final Rule, the Centers for Medicare & Medicaid Services (CMS) formally finalized the removal of the Screening for Social Drivers
For decades, clinical documentation integrity (CDI) programs have been synonymous with inpatient care. They evolved from early efforts to improve Diagnosis-Related Group (DRG) accuracy into
Please log in to your account to comment on this article.
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.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
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
