The recent settlement between Kaiser Permanente and the federal government marks a pivotal moment in the ongoing debate over risk-adjustment practices in Medicare Advantage (MA)
EDITOR’S NOTE: Gloryanne Bryant has more than 40 years of experience in her field and is an independent HIM Coding and CDI Consultant who works
One of my favorite resources is Insights, distributed by Kodiak. Let me begin by noting that I do not have any affiliation with Kodiak. I
As discussed in my prior articles, Medicare Advantage (MA) organization payments incorporate a beneficiary’s health risk, as determined by diagnoses that map to Centers for
As discussed last week, payments to Medicare Advantage (MA) plans are adjusted to account for expected healthcare resource consumption by enrollees. Higher risk scores increase
In an ideal world, every diagnosis code you submit to the Centers for Medicare & Medicaid Services (CMS) would be backed by bulletproof documentation –
The shift from fee-for-service to value-based care (VBC) is reshaping how healthcare organizations are reimbursed and evaluated. In this new environment, success hinges not only
The traditional narrative that risk-adjustment coding is exclusive to Medicare Advantage (MA) is no longer accurate. In 2025, commercial insurers, particularly those managing Patient Protection
Hospitals nationwide are preparing for significant regulatory shifts driven by the Centers for Medicare & Medicaid Services (CMS). The FY 2026 Inpatient Prospective Payment System
A listener, who is a risk adjustment program manager, asked me to elucidate when a congenital condition code is appropriate. She was most interested in
As providers expand the use of telehealth, HHS will continue to include select telehealth and telephone-only services in its risk-adjustment programs. Hierarchical Condition Category (HCC)
The number of conditions a patient has is now going to factor into the risk adjustment score (RAS). EDITOR’S NOTE: Dr. Erica Remer reported this
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.
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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.
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