Hospital reimbursement
A 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 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 MoreThis is what a good outpatient CDI program looks like
By Jason Jobes This, right here. You should be focused on risk score accuracy by simultaneously evaluating how to maximize revenue and mitigate risk. We believe that every organization should get every penny it deserves, just not a penny more. Many organizations have started outpatient, or ambulatory, CDI programs focused solely on risk score maximization. Don’t do that. If you aren’t trying to ensure the…
Read MoreDon’t sleep on two important new changes hitting Jan. 1: Mandatory TEAM model and CMS-HCC V28 full payment shift
By Brian Murphy January 1 is rapidly closing in, and 2026 is bringing new rules and regulations impacting the mid-revenue cycle. Here’s two you shouldn’t forget about. Consider this a public safety announcement. V28 of CMS-HCCs Say goodbye to V24, and hello (fully) to V28. This one feels manageable. We’ve all been dealing…
Read More2026 OPPS final rule does no favors for our nation’s hospitals
By Brian Murphy The OPPS final rule, incredibly late this year, is finally out. Here I piece together some thoughts on (generously) four hours of sleep after a late night trip to Boston to pick up my daughter from a weekend getaway, so excuse any illogic. You can read the fact sheet easily enough (see…
Read More