Posts by Brian.m
Risk Adjustment Reality Check: What’s Working—and What Isn’t
Listen to the podcast. This year has been something of a reckoning for Medicare Advantage. Senator Grassley’s scathing report of UHG’s risk adjustment practices, and the Kaiser $556 million settlement to resolve False Claims Act allegations of upcoding, opened eyes, and got many in the industry talking. I wanted to get someone on the show with opinions, unafraid to speak their mind and share their perspective. I’ve found that person. Betty Stump is Senior Solution Consultant…
Read MoreDo you follow the GOLD standard for COPD diagnosis and management, mid-revenue cycle professionals?
By Brian Murphy Are you following the GOLD standard for COPD diagnosis and management? Medscape has a great article and video on this underreported diagnosis by Dr. Neil Skolnik. See link below. Here’s why I recommend it. As always with articles of this sort I caveat that I’m not a clinician and I have a…
Read MoreNorwood publishes analysis of CMS 2027 Advance Notice
Download the guide here. Medicare Advantage just shifted again — and 2027 is already reshaping your 2026 strategy. If you think the 2027 Advance Notice is just another routine CMS update… think again. Inside this guide, we break down: 📉 A projected $1.2M funding reduction per 10,000 MA lives 📊 $2.3M impact tied to coefficient…
Read MoreMorbid obesity vs. Class 3 obesity for medical coding: Which to use—and which is accepted?
By Brian Murphy A mid-revenue cycle professional lamented on a recent call that their CDI program is hindered because physicians don’t want to diagnose “morbid obesity.” It has become a fraught term, seen as demeaning to the patient. I get it. The good news is, Class 3 obesity has come to the rescue. Or has…
Read MoreA reckoning for Medicare Advantage: Inside the Kaiser case with Mary Inman and Liz Soltan
Listen to the episode here. Medicare Advantage is undergoing a reckoning … and that reckoning is coming from within. In January Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that it violated the False Claims Act by submitting invalid diagnosis codes for their MA Plan enrollees in order to receive higher payments…
Read MoreA very bad start to the year for Medicare Advantage; whistleblowers and government officials expose questionable risk adjustment coding practices
By Brian Murphy This has been a terrible start to the year for Medicare Advantage. Senator Chuck Grassley’s report “How UnitedHealth Group Puts the Risk in Medicare Advantage Risk Adjustment” landed like a bombshell on Jan. 12. It revealed the extent of UHG’s “robust diagnosis capture workforce,” from advanced analytics to in-home health assessments…
Read MoreFrom Encephalopathy to Edema: Talking chart review with Dr. Tarman Aziz
Listen to the episode here. I’m consistently surprised at how few CDI or IP coding professionals talk about their most basic job function. The very reason they are hired, and what most do for eight hours a day. I’m talking about chart review. Go on Linkedin or Facebook and it’s rarely discussed. Yet it’s … everything. Nuanced, complex, clinical, critical to the quality of financial health of hospitals. It’s how patient acuity is expressed in coded data, how hospitals get paid, and why CDI and coding professionals are employed. …
Read MoreIt’s OK to ask direct (but not leading) queries to the provider, CDI professionals
By Brian Murphy Ask direct queries. It’s OK. Sometimes we get so fixated on query format we fail to see forest through the trees. The point of a query is to ask a pointed, clinically relevant question and allow the physician to exercise his/her independent judgement. We should be asking direct no-nonsense queries, especially in…
Read MoreDownload The State of Value-Based Care, our latest white paper.
We’re kicking off 2026 with a special report on The State of Value-Based Care. This paper shows where we are nationally with CMS’ stated goal of Every Traditional Medicare beneficiary in an accountable care relationship by 2030. It also offers critical tips and strategy on compliant risk adjustment, depiction of patient illness, and compliance with…
Read MoreHow do CDI professionals review the medical record (and how has tech changed the game)?
By Brian Murphy I’m always amazed at how little the core function of CDI gets discussed. I’m talking about medical record review. How it’s actually done, the process. For example: Where do you begin when reviewing the record? What steps do you take, and in what order? For inpatients, how long do you wait…
Read More