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
Medicare regulations are complex and even seasoned professionals struggle to apply them consistently. Due to overwhelming demand, Dr. Hirsch returns for Part 2 of Ask Dr. Hirsch: Clarifying Medicare’s Most Misunderstood Rules to answer even more of Medicare’s most misunderstood questions, covering inpatient status, observation, SNF access, Medicare Advantage denials, and more. Join Dr. Hirsch as he provides clear, referenced answers to real-world questions submitted by your peers, helping you navigate Medicare compliance with confidence and clarity.
Traditional utilization management models can no longer keep pace with regulatory shifts, payer scrutiny, and operational pressures. In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, ACPA-C, introduces an Adaptive Model strategy that modernizes UM through role specialization, technology-driven workflows, and proactive, team-based processes. Attendees will learn how to restructure programs to improve efficiency, strengthen clinical collaboration, and enhance financial performance in a rapidly changing healthcare environment.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
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.
Prepare for FY 2027 IPPS changes with a comprehensive 3-part masterclass covering ICD-10-CM/PCS updates, MS-DRG shifts, NTAPs, compliance risks, and reimbursement strategies.
Stay ahead of FY 2027 reimbursement changes with expert analysis of MS-DRG shifts, NTAP updates, Medicare Code Edits, and emerging technologies impacting inpatient payment accuracy.
Stay ahead of FY 2027 ICD-10-PCS changes with expert analysis of new procedure codes, revised guidelines, and high-impact updates affecting reimbursement, compliance, and inpatient coding accuracy.
Master the FY 2027 ICD-10-CM changes, including new diagnosis codes, CC/MCC updates, and coding guideline revisions, with practical insights from nationally recognized coding and CDI experts.
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