News
3 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…
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 MoreTrump administration’s appeal of vacated RADV rule indicates Medicare Advantage audits not going away
By Brian Murphy Nothing is over. We’re still deep in the wild west of Medicare Advantage (MA). In case you missed the breaking news over the Thanksgiving break, the Trump administration on Friday appealed a crucial court decision. In September a TX judge ordered the 2023 Risk Adjustment Data Validation (RADV) rule vacated, removing CMS’…
Read MoreNew WISeR model puts CMS squarely in the preauthorization business, for the first time
Effective Jan. 1, 2026, CMS is getting into the prior authorization business. The Wasteful and Inappropriate Service Reduction (WISeR) Model is a pilot program set to run for six years, initially in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. It introduces new prior authorization processes for certain high-risk Medicare Part B services…
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