November 5, 2026
Cigna is the latest health insurance company to boost its guidance for the year on the back of its Q3 results.
This article was originally published on Fierce Healthcare.
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November 5, 2026
Cigna is the latest health insurance company to boost its guidance for the year on the back of its Q3 results.
This article was originally published on Fierce Healthcare.
Author: Knicole C. Emanuel Esq. | November 4, 2026
For many providers, the first sign of trouble is a records request from a Medicare contractor. Recovery Audit Contractors, (RACs) are private firms hired by the Centers for Medicare & Medicaid Services (CMS) to find and correct improper fee-for-service payments. They work alongside Medicare Administrative Contractors (MACs), which process claims and conduct their own medical reviews, and Unified Program Integrity Contractors (UPICs), which focus on suspected fraud and abuse.
RACs are paid a percentage of what they recover. Contractors can also extrapolate errors in a small sample across thousands of claims, producing seven-figure demands. Many denials, however, are reversed on appeal.
The Story: In Home Health, LLC v. Kennedy
In Home Health, a hospice provider, faced a demand for roughly $1 million after Medicare contractors denied hundreds of its claims. The MAC concluded that many patients did not meet the definition of “terminal illness” in a local coverage determination. The denials were upheld by a Qualified Independent Contractor and then by an administrative law judge (ALJ).
Beyond arguing that each patient qualified, the hospice invoked Section 1879 of the Social Security Act, the “limitation on liability” provision, which protects a provider that reasonably believed a service would be covered. The ALJ rejected that defense because the hospice knew about the governing Medicare notice on hospice standards.
On July 27, 2026, the U.S. Court of Appeals for the Sixth Circuit held that the ALJ applied the wrong test. The question is whether the provider reasonably interpreted the rules, not whether it knew them. In the court’s words, if a provider “reasonably – albeit incorrectly” read the Medicare standards as covering a claim, “the safe harbor saves them from liability.” The court sent the case back to the ALJ to apply that standard.
Two cautions apply. The win is a remand, not a final victory, and the decision binds only federal courts in Kentucky, Michigan, Ohio, and Tennessee.
Key takeaways:
Conclusion: Best Practices
Begin with documentation. Answer every Additional Documentation Request completely and on time, making sure the records clearly support medical necessity. When a RAC issues an adverse finding, use its informal discussion period. The RAC may reverse itself if you send additional records.
Then calendar the deadlines carefully:
Finally, bring in counsel early, especially for extrapolated demands or any sign of a fraud referral. Medicare audits can be won, but usually only by providers who build the record, respect the clock, and are prepared to take the fight to an independent judge.
This article was originally published on RACmonitor.
November 4, 2026
Avanlee Care helps MA plans and other organizations engage caregivers within their member populations, enabling them to take action and measure what happens as a result.
This article was originally published on Fierce Healthcare.
November 4, 2026
CVS Health is splitting up. The healthcare giant announced Wednesday morning that it would divide its business units into two companies.
This article was originally published on Fierce Healthcare.
November 3, 2026
The move reflects Humana’s broader strategy to improve care access through requiring fewer prior authorizations and making the process simpler when needed, executives say.
This article was originally published on Fierce Healthcare.
Author: Christine Geiger, MA, RHIA, CCS, CRC | October 26, 2026
If you have spent any time watching TV lately, you surely have been bombarded with commercials about Medicare Advantage (MA) plans. Medicare open enrollment ends on Dec. 7, so we will be seeing them for a few more weeks. I find myself listening a little bit closer each year as I creep toward that eligibility age, but I will be glad when Dec. 8 rolls around. For our Focus on Fraud this week, we will be looking at the MA Compliance Audit performed by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), centering on of UnitedHealthcare Benefits of Texas, Inc.
Published September 2026, this audit is one in a series where the accuracy of diagnosis codes MA organizations submit to the Centers for Medicare & Medicaid Services (CMS) is reviewed. This particular audit focused on 11 high-risk groups of diagnosis codes; these were identified as acute stroke, acute myocardial infarction, embolism, lung cancer, breast cancer, colon cancer, prostate cancer, ovarian cancer, sepsis, pressure ulcer, and diagnoses that are potentially mis-keyed or entered or submitted incorrectly.
As coders, when we hear that list, we easily can conceive of some of the potential challenges associated with them. It might be due to the supporting documentation, or lack thereof. Maybe the coders are unclear on cancer coding guidelines…and then there is sepsis. The bottom line is that as coders, we know the potential for inaccuracy with these diagnosis code groups.
The audit included a sample of 230 claims wherein program enrollees had a reported high-risk diagnosis in service years 2019 and 2020. UnitedHealthcare then would have received risk-adjusted payments for payment years 2020 and 2021. A total of 200 claims of this sample were related to the high-risk diagnosis groups, and 30 of the sample were those potentially mis-keyed diagnoses.
The good news is that for 58 claims of the sample of 230, medical record documentation supported and validated the reported Hierarchical Condition Category (HCC). For the remaining 172, however, either the medical records could not be located, or the documentation did not support the reported HCC.
The audit sample showed a total of $622,927 in overpayments because of the unvalidated HCCs. While that is a large number, remember, this was just the sample. Based on those results, the OIG estimated that the total overpayment based on unvalidated HCCs for 2020 and 2021 was $24,465,369. UnitedHealthcare reportedly does disagree with some of the findings, and I encourage you and your staff to review the full audit report. I have included the link to the report in my article this week.
For a further breakdown on the findings by diagnosis, the OIG notes that acute stroke codes were incorrectly submitted on 19 of 20 sampled. For the acute myocardial infarction, 17 of 20 were submitted incorrectly. Embolism codes were incorrectly submitted on 15 of 20.
On the cancer types, as a combined number, only 9 of 100 sampled were submitted correctly. Sepsis and pressure ulcer scored a bit better, with 7 of 20 incorrectly submitted sepsis codes and 5 of 20 incorrectly submitted codes for pressure ulcer.
The potential mis-keyed diagnoses accounted for 18 incorrectly submitted codes out of the sample of 30.
Whether you code MA accounts or not, I would encourage you to review the findings and identify potential problem areas, especially within the identified high-risk diagnosis groups, for which coders may need a guideline refresher or additional education.
This list is a great place to start to either perform a focused review on your team or prepare some learning opportunities.
This article was originally published on RACmonitor.
October 26, 2026
Earlier this year, UnitedHealthcare unveiled Avery, a generative AI companion aimed at supporting care coordination for its members.
This article was originally published on Fierce Healthcare.
October 26, 2026
The final rule retains most of the core objectives from the December 2025 proposal, but ONC significantly scaled back its approach, stopping short of the sweeping overhaul of the health IT certification program it initially proposed.
This article was originally published on Fierce Healthcare.
Author: Bryan Nordley | October 26, 2026
Question:
What can lead to payer denials of code 92972, and how can providers support the code through documentation?
Answer:
Although code 92972 was created to report this service, many payers are denying this code as not medically necessary or because the documentation does not contain enough information to support the use of this code. Providers are strongly encouraged to include in their procedural documentation why this service was medically necessary in addition to the PCI.
This article was originally published on RACmonitor.
October 23, 2026
Building stronger bridges between payers and providers will prove critical in addressing the biggest challenges facing healthcare: affordability and access.
This article was originally published on Fierce Healthcare.