News
If a GLP-1 drops your BMI under 35, is morbid obesity off the table?
By Brian Murphy At the ACDIS conference last week, an interesting obesity coding question posed during a Q&A session at the Outpatient Symposium: Should we continue to code morbid obesity for patients who were previously morbidly obese (BMI greater than 35 with obesity-related comorbidities), but because they are on an active GLP-1 their BMI is…
Read MoreNew ACDIS/AHIMA physician query practice brief (2026) puts mid-revenue cycle leaders front and center in compliance
By Brian Murphy At the ACDIS conference last week, a bombshell announcement: A new physician query brief, the joint output of ACDIS/AHIMA. You can read it here on the ACDIS website. The organizations are accepting comments through June 12, and may make changes based upon them. So, give it a thoughtful read and submit your…
Read MoreCMS 2027 Medicare Advantage final rate announcement: What changed, what it means
Regardless of how you feel about Medicare Advantage (MA), CMS is doubling down on the embattled program with the 2027 MA and Part D Rate Announcement. CMS reversed course on the advance notice and removed a proposed risk model recalibration which would have resulted in a payment cut for most MA plans. Instead, MA plans…
Read More3 things to know about the 2027 IPPS proposed rule
By Brian Murphy The 2027 IPPS proposed rule is out… here’s 3 things I found interesting. (There are more than 3 things in it… but what do you do with 1586 pages of rules? You limit to three things). As always with proposed rules, big caveat: All of this is PROPOSED, subject to a comment…
Read MoreA must watch: New CMS video signals new metric for Medicare Advantage
By Jason Jobes The 2027 Medicare Advantage final rate notice is out—and the buzz is everywhere. Let me just say I rarely pause to watch a video, much less one that is 20 minutes. This one is a MUST watch if you are in risk adjustment. Last week “Health Tech Nerds” hosted an interview with…
Read MoreGrassley Report of UnitedHealth Group takes aim at these 20 diagnoses: Here’s why
By Brian Murphy The Grassley Report examining the risk adjustment practices of UnitedHealth Group (UHG) is much more than just a one-time media splash. The report is 105 pages long and contains a wealth of information and insight into how UHG does its work. This includes the criteria it uses to report diagnoses to…
Read MoreFinancial success of Comprehensive Care for Joint Replacement (CJR) model paved way for TEAM
By Brian Murphy The Comprehensive Care for Joint Replacement (CJR) model is over, and it generated savings to Medicare. How much? We await the grand total, as final performance year financial results are expected later this year. But the latest, just released data (see attached graphic) shows that the CJR generated a whopping $112.7…
Read MoreNew 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 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 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…
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