Hospital reimbursement
New Norwood special report examines latest trends in payer denials
Download the report here. Denials are being turned up, not down. But they’re happening in less noticeable and more insidious ways, often under a different name. Aided by new AI technologies, payers are finding increasingly creative ways to deny claims outright or blanket reduce payments–a soft equivalent to a denial. This report examines some of…
Read MoreYou need to have it both ways: Audits must target missed coding opportunities and invalid conditions in risk adjustment
By Brian Murphy Among the alleged behaviors that led to Kaiser’s eventual $556M payout to settle false claims act allegations was its aggressive effort to only add diagnosis codes (up to a year or more after the encounter) and never remove them. This is called a one-way audit, and the Department of Justice does not…
Read MoreFive things to know about Present on Admission (POA) for hospital payment, quality
By Brian Murphy Present on admission (herein POA) for coding purposes is defined as conditions that are present at the time the order for the inpatient admission occurs. It’s important to get POA status right, as it impacts payment and quality metrics. POA conditions (as reported with a Y) count as CCs or MCCs, whereas…
Read MoreHow a baseline became a springboard to documentation, coding improvement
What gets measured, gets managed. An old business truth … but we don’t always think of the inverse. Without a baseline, you won’t know where to focus. An integrated healthcare system comprised of county-owned hospitals and clinics suspected it was leaving severity and revenue on the table, but wisely didn’t want to dive straight into education without a clear starting line. With its provider and coding teams busy delivering care and getting claims out the door it turned to Norwood for help. Our work …
Read MoreRisk 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…
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