If a patient is insured by UHC Medicare Advantage, it appears that almost anything goes when it comes to determining the correct admission status. In
Those charged include dozens of licensed medical professionals. Healthcare fraud, by its nature, clearly tends to resist being narrowly defined. It was a point driven
Understanding the intersection of COVID-19 and SDoH. Over the past 20 months, I’ve reviewed countless nooks and crannies of COVID’s intersection with the social determinants
Targeted Probe-and-Educate (TPE) audits resumed on Sept. 1. Everyone in the industry knows about audits of healthcare providers. But what about the billing companies? Or
This is the largest Medicare Advantage fraud settlement involving a hospital group. Late last month, Sutter Health, a healthcare giant operating more than 20 hospitals
All diagnoses should be clinically valid. Denial of reimbursement for medical care occurs for a multitude of reasons, including incomplete or inaccurate information, lack of
Rationing of patient care: everything is different, but nothing has changed. EDITOR’S NOTE: Crisis Standard of Care, first reported here on RACmonitor, occurred in the
Idaho has activated crisis care standards throughout the state. EDITOR’S NOTE: The Idaho Stateman reported Thursday that the Idaho Department of Health and Welfare has
Your health system should define your own standard for infrequency. EDITOR’S NOTE: For valuable context to this article, the author suggests the Dr. Juliet Ugarte
Many states are implementing payment parity on a permanent basis. Every time a regulation is revised, Medicare and Medicaid audits are altered…sometimes in the providers’
Hunger and food insecurity cost the U.S. economy more than $160 billion in poor health outcomes. Another week, another report on Americans facing concerning access
President Biden’s executive order heralding mandates for COVID-19 vaccination may not have teeth, but the overall direction of federal guidance has been made abundantly clear.
Medicare regulations are complex and even seasoned professionals struggle to apply them consistently. Due to overwhelming demand, Dr. Hirsch returns for Part 2 of Ask Dr. Hirsch: Clarifying Medicare’s Most Misunderstood Rules to answer even more of Medicare’s most misunderstood questions, covering inpatient status, observation, SNF access, Medicare Advantage denials, and more. Join Dr. Hirsch as he provides clear, referenced answers to real-world questions submitted by your peers, helping you navigate Medicare compliance with confidence and clarity.
Traditional utilization management models can no longer keep pace with regulatory shifts, payer scrutiny, and operational pressures. In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, ACPA-C, introduces an Adaptive Model strategy that modernizes UM through role specialization, technology-driven workflows, and proactive, team-based processes. Attendees will learn how to restructure programs to improve efficiency, strengthen clinical collaboration, and enhance financial performance in a rapidly changing healthcare environment.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
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.
Artificial intelligence is rapidly transforming healthcare revenue cycle operations, from coding and auditing to compliance and denials. Join industry leaders Pam Warren (MaineHealth) and Raemarie Jimenez (AAPC) for a live fireside chat exploring how AI is changing workflows, workforce roles, payer-provider dynamics, and compliance risk—and what organizations should be doing now to prepare.
Prepare for FY 2027 IPPS changes with a comprehensive 3-part masterclass covering ICD-10-CM/PCS updates, MS-DRG shifts, NTAPs, compliance risks, and reimbursement strategies.
Stay ahead of FY 2027 reimbursement changes with expert analysis of MS-DRG shifts, NTAP updates, Medicare Code Edits, and emerging technologies impacting inpatient payment accuracy.
Stay ahead of FY 2027 ICD-10-PCS changes with expert analysis of new procedure codes, revised guidelines, and high-impact updates affecting reimbursement, compliance, and inpatient coding accuracy.
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