When I was a resident, no one ever said to me, “Pay attention. One day this will matter when you are explaining medical necessity to
Beginning in 2026, the Centers for Medicare & Medicaid Services (CMS) will begin phasing out the Inpatient-Only (IPO) List by removing predominantly musculoskeletal and complex
In the Medicare fee-for-service world, “prepayment review” (also sometimes called “prepayment medical review” or “pre-claim review,” depending on the context) means that a claim is
Ok, I will admit that I am a glass-half-empty guy. I would love to always see the positives in things, but someone has to be
In a recent article in the prestigious New England Journal of Medicine, a rheumatologist at a teaching hospital lamented about “hospital problems,” a recent phenomenon
Providers need to fight for their patients in ways the insurance companies don’t. Medicine is both an art and a science, not a game. Screening
Hospitals and health systems are increasingly turning to innovative methodology to cope with staffing and budget constraints. Utilization review (UR) has been in place for
CMS is discontinuing certificates for medical necessity and durable medical equipment. CMS is discontinuing Certificates of Medical Necessity and Durable Medical Equipment (DME) information forms
Covid, OPPS and medical necessity certificates are reported here. There is good news on the COVID-19 public health emergency (PHE) front. We now know the
A recent study showed that some common orthopedic procedures aren’t routinely supported by data. As I am sure others will note, Jan. 1 marked the
Care that provides little or no benefit to the patient, with possible harm, is often referred to as low-value care. One of the most common
Medical necessity guidelines must also be carefully reviewed for their applicability to the individual patient. The term “medical necessity” is used far and wide in
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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