Providers need to fight for their patients in ways the insurance companies don’t.
Medicine is both an art and a science, not a game. Screening criteria, scoring systems, and guidelines like InterQual and MCG help determine medical necessity and patient status: inpatient or outpatient.
Culled from huge data sources, they represent a scientific way to apply medicine to populations, not individuals. They allow prompt recognition of specific diagnoses and suggest effective interventions: concepts like the golden six hours of management for open fractures or limb ischemia, or prompt initiation of antibiotics and fluids in the septic patient. Prompt intervention may head off unwanted outcomes. Unfortunately, they are not guarantees of success. They are not the ultimate source of information.
Applying these scientific criteria without oversight can be risky. Classic appendicitis presents 10 percent of the time. It takes the seasoned professional to lay hands on the individual and determine their true status. The Centers for Medicare & Medicaid Services (CMS) recognizes this art as superior to the scientific guidelines. So, the dilemma exists of how physician advisors and physicians can use specific patient experiences to argue against detailed guidelines based on populations. We thought it would direct conversations on medical necessity, not be used to manipulate status determination, a clearly recognized administrative term.
As physician advisors, we are faced with using the written notes to argue for status and care. Clinical notes communicate the patient’s symptoms, signs, assessment, and proposed treatment. The healthcare team should update the notes and plans depending on the patient’s response.
Regretfully, this communication may not result in the optimization of the patient’s length of stay. Longer notes using cutting and pasting don’t guarantee inpatient status or better charge capture. Hospitals should encourage directed chart notes to avoid redundancy.
Specialists should identify key factors that are significant to their fields, plans, risks, and outcomes. Providers should be concerned with delivery of care, not administrative assignment. CMS is now focusing on medical decision-making or time, not just categories that encourage note bloat.
As physician advisors, we are perfectly positioned to guide, not lead, them to effective and efficient documentation, to ensure that their patients receive the right care at the right time in the right setting. We can remind them to tailor their notes to identify key factors for the diagnoses they are highlighting. Save them time! Target the systems at risk! How many notes on encephalopathy even try to use the prompt neuro exam of our training: recall immediately, at one minute and at five minutes for yellow, sneaker, and river unprompted, or from a list. Or respiratory distress with pneumonia: work of breathing, cough, speaking, accessory muscles, wheezing, respiratory rate, hypoxia, egophany (my favorite, even as a surgeon). Should we write “decreasing in severity” rather than “improved?” Our physicians’ notes have to be internally consistent and not give the insurer ammunition to support their denials. Specialists may identify their area of concern as resolved, but should indicate that the patient’s entire issue may be more complex.
In contrast to mutual fund giant Vanguard, whose members are their shareholders, insurers answer to their shareholders and stockholders, not their patients. Insurers reduce patients into objective numbers, avoiding any emotional connection and allowing them to limit treatment. So, treat them as such. UnitedHealthcare (UHC) has tried to control their costs with sepsis by requiring patients to meet Sequential Organ Failure Assessment (SOFA) criteria.
No wonder states like New York try to fashion laws to prevent abuse, but find them watered down by interested parties, leaving them outdated before they are signed into law. The medical community resisted, but even in Ohio, we found Medicaid using SOFA. “Surviving Sepsis 2021” tried to clarify sepsis, but is disregarded by insurers, as it doesn’t support their desire to restrict care. Insurers modify certain factors in the scoring system to minimize them when certain disease factors may alter the baseline.
Why is CMS trying to redefine prior regulations to avoid Medicare Advantage (MA) plans’ misapplication? CMS has no problem inferring fraud and extrapolating damages against hospitals and providers without a lookback time restriction if fraud is suspected. Why are they hesitating to use the same approach with MA plans? I don’t think that the government expected a profit bonanza from Medicare management when they created the commercial opportunity.
Surprisingly, when insurers are faced with a patient meeting a guideline like MCG and a length of stay over two midnights, they frequently deny based on poorly defined proprietary policies, delayed application of presentation criteria, intensity, or biased interpretations of CMS regulations. It is enough to make me dizzy. I’m still trying to understand how a patient who required BiPAP, admission to the ICU, and discharge on a new oxygen requirement did not meet inpatient status. Why do we let insurers define the rules?
Insurers admit that they don’t determine medical care. As noted, insurers reduce patients, their policyholders, to numbers, avoiding emotional connections, limiting treatment, and restricting care. Insurers modify certain values to minimize the scores when certain disease factors seem “inconvenient.” UHC even bought InterQual. Seems a clear conflict of interest? At least directed physician documentation will offer a good chance for overturn on further appeal. We should advocate for the patient, encourage them to lodge grievances, even with CMS, and not stop appealing until all opportunities are exhausted. Clearly, a success rate of 40 percent at the administrative law judge (ALJ) level indicates the value of pursuing justice for our patients beyond the insurer.
Medicine remains not only a science, but an art. Art requires a deft touch to appropriately apply the science for the specific individual. We need to base our care on the patient in front of us. They are not a “diabetic” or a systemic inflammatory response syndrome (SIRS) patient; we need to resist bundling them into a neat package so their care can be minimized. They mean much more than that.
Don’t sell patients short. Stop treating it as a game. Truth be told, we’d be playing the insurers’ game from behind, as they change the rules as soon as we respond to the old rules.
Today we’re talking about a major shift in Medicare rules that’s going to impact hospitals, surgeons, and physician advisors alike: the phasing out of the
Let’s talk about the term “attending physician.” The simplest definition is the physician primarily responsible for a hospitalized patient’s care. While there may be many
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.
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.
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.
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
