The Rules Don’t Apply: Private Payers
David M. Glaser, Esq.
February 16, 2017
A client called me this week after receiving the results of an audit by a private insurer. While I have done Medicare audits for clients
A client called me this week after receiving the results of an audit by a private insurer. While I have done Medicare audits for clients
The advent of revised regulations for administrative law judge (ALJ) hearings of Medicare appeals includes a new request for ALJ hearing or review of dismissal
FEATURING Janelle Ali-Dinar, PhD; Nancy Beckley, MS, MBA, CHC; David Glaser, Esq.; Emily Evans; Ronald Hirsch, MD, FACP, CHCQM; and Stanley Sokolove, CPA
Despite vigorous protests by Senate Democrats, the U.S. Senate today confirmed President Trump’s nomination of Rep. Tom Price (R-Ga.) to helm the U.S. Department of
Sept. 10, 2004 was a day of mixed blessings in the case management world. On that day, the Centers for Medicare & Medicaid Services (CMS)
EDITOR’S NOTE: A 9th Circuit Court of Appeals has yet to issue a decision on the federal government’s request to lift a district court judge’s
Durable medical equipment (DME) suppliers have a target on their backs. It is likely that they are subjected to the most frequent audits of any
Now that the new presidential administration has taken office, we can expect some modifications to the Medicaid program as an entitlement arrangement. Currently, everyone who
FEATURING Janelle Ali-Dinar, PhD; Nancy Beckley, MS, MBA, CHC; Emily Evans; David Glaser, Esq.; Ronald Hirsch, MD, FACP, CHCQM; and J. Paul Spencer, CPC, COC
With millions of rural Americans at risk of losing health insurance and direct access to care, an unprecedented number of National Rural Health Association (NRHA)
With the recent federal court order for the Secretary of the U.S. Department of Health and Human Services (HHS) to clear up the three-year, million-case
Provider-based clinics and other provider-based operations have become very popular with hospitals and integrated delivery systems. One of the reasons for the popularity is the
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
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