I recently offered training to a health system about how to respond to whistleblower complaints. Regular readers will know many of the tips I discussed.
Healthcare compliance just got a lot more complicated. We’re not dealing with traditional whistleblowers anymore – the ones who needed inside access to spot problems.
The U.S. Department of Justice (DOJ) announced a settlement of up to $100 million with Independent Health, a Medicare Advantage (MA) plan serving upstate New
Earlier this month, a toxicology lab doing business as Precision Diagnostics agreed to pay $27 million to resolve allegations raised by three whistleblowers under the
A recent whistleblower case decision has revealed how federal prosecutors going after providers for fraud have been frustrated by the murkiness of federal regulations. United
The DOJ Sept. 13 filing of a complaint in intervention in a case against Buffalo-based Independent Health (IH) and its coding consultant subsidiary, DxID is
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
The government’s most drastic power is its ability to dismiss the case entirely. Recently, a three-judge panel of the U.S. Court of Appeals for the
The suits allege that defendant Kaiser Permanente inappropriately inflated reimbursement applications for Medicare Advantage beneficiaries. In a titanic legal battle over healthcare reimbursement, a prominent
Email is a wonderful thing. As a kid, or even as an adult, I rarely wrote letters because the act of addressing an envelope was
Late last week, Integra Med Analytics, a corporate whistleblower that has filed several lawsuits alleging healthcare fraud, was dealt its latest blow when the Fifth
The saga of increased scrutiny of Medicare Advantage plans continues to unfold. UnitedHealthcare’s SuspensionCMS announced a suspension of one year for the UnitedHealthcare H5322 contract
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.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
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.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
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