September 15, 2026
A trove of CMS documents obtained and shared by a privacy nonprofit outlines sweeping issues such as delayed approvals, miscommunication and provider frustration.
This article was originally published on Fierce Healthcare.
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September 15, 2026
A trove of CMS documents obtained and shared by a privacy nonprofit outlines sweeping issues such as delayed approvals, miscommunication and provider frustration.
This article was originally published on Fierce Healthcare.
Author: Juliet Ugarte Hopkins, MD, ACPA-C | September 15, 2026
Documentation in utilization review (UR) is practical daily work, but it carries significant operational, financial, and compliance weight. For physician advisors, especially those reviewing patient status, the documentation standard should be more than a one-word answer. A note that says only “inpatient,” “observation,” or “outpatient in a bed” may provide the utilization management team a recommendation, but it does not explain the clinical thinking behind it.
In medicine, the importance of documentation is taught early. Physicians, nurses, therapists, pharmacists, and many other professionals learn the familiar principle: if it was not documented, it did not happen. That same principle should apply when a clinician moves into the physician advisor role. Physician advisor notes don’t include treatment plans and aren’t written for bedside care, but they are still part of the record of decision-making. They should identify the case being reviewed, the clinical issue in question, and the rationale behind the status recommendation.
Too often, status escalations receive a brief response. A utilization manager requests a secondary review because the correct status is unclear, and the physician advisor responds, “inpatient.” Or, “observation.” The answer may be correct, but it leaves out the most important element: why. What about the patient’s presentation, severity of illness, intensity of service, treatment plan, risk of deterioration, comorbidities, or response to treatment supports the recommendation? What supported inpatient status? What made outpatient status with observation services more appropriate? Centers for Medicare & Medicaid Services (CMS) regulations recognize that inpatient status judgments depend on complex medical factors, including past medical history, comorbidities, severity of signs and symptoms, current medical needs, and risk of an adverse event. The factors supporting that expectation must be documented in the medical record.
The difference between a one-word recommendation and a brief rationale becomes clear when a denial arrives. If the physician advisor documented the reasoning at the time of review, the denial team can begin with that clinical thought process, rather than reconstructing the entire case weeks or months later. A concise note can frame a peer-to-peer discussion, support an appeal letter, and demonstrate that the status recommendation was tied to the patient’s condition and anticipated course at the time of hospitalization. It also helps separate contemporaneous clinical judgment from hindsight, which is especially important when the patient improves more quickly than expected.
Clear documentation is equally important during Recovery Audit Contractor (RAC) reviews and other governmental audits. An organization may discover that its physician advisors consistently supported inpatient status, but left no explanation of the medical necessity for a second midnight or the reasonableness of anticipating a two-midnight stay. In that situation, the organization may have had sound clinical judgment, but weak documentation of that judgment. The same concern applies to Condition Code 44 cases. When a Medicare beneficiary’s status is changed from inpatient to outpatient before discharge, they lose their right to appeal their discharge. In this instance as well, it’s important to identify the precise reasoning for the change in status.
Good physician advisor documentation also serves an educational purpose. Many secondary reviews are requested because the status decision is not obvious. A note that reads only “observation” does not help the next utilization manager recognize a similar clinical pattern. A brief explanation, however, can teach the logic behind the recommendation and improve consistency across future reviews. Over time, these notes become a practical teaching tool. They clarify how the organization applies regulatory guidance, payer expectations, and clinical judgment to real patients. They also help new utilization managers learn what details matter most when escalating a case for review.
If physician advisors report that they do not have time to document their rationale, leaders should evaluate the workload, rather than simply accepting shorter notes. It is important to count all secondary reviews, not only status cases. Peer-to-peer work, interdisciplinary rounds, huddles, meetings, denial support, and other daily responsibilities all compete for time. If the workload is too high to allow defensible documentation, the answer may not be less documentation, but rather additional physician advisor support, clearer escalation criteria, smarter workflows, or templates that make concise rationale easier to capture. The goal is not lengthy prose, but a short, clear explanation of the clinical judgment behind the recommendation.
Status recommendations need rationale. Clear documentation protects the organization, supports appeals, strengthens compliance, and helps the whole utilization review team learn from each case. In the end, a thoughtful physician advisor note is more than a status decision. It is a record of clinical judgment, a bridge between utilization management and medical necessity, and a safeguard for patients and organizations alike.
This article was originally published on RACmonitor.
September 15, 2026
A new report from Reuters is fueling speculation that healthcare payment software maker Waystar is exploring strategic alternatives, including a potential sale that could take the company private.
This article was originally published on Fierce Healthcare.
Author: Christine Geiger, MA, RHIA, CCS, CRC | September 14, 2026
We are already halfway through September, so time has flown by since we first started thinking about the Inpatient Prospective Payment System (IPPS) Final Rule for the 2027 fiscal year (FY). Oct. 1 is truly right around the corner.
To help you prepare, today we will focus on some topics covered in the FY 27 IPPS Masterclass.
First up is vanishing twin syndrome and the new ICD-10-CM codes for this condition. Vanishing twin syndrome is the spontaneous loss and resorption of one or more fetuses in a multifetal pregnancy. In vanishing twin syndrome, at least one fetus continues to develop. While this is not new, it is being identified more due to the increased incidence of routine first-trimester ultrasound examinations being performed. Surviving fetuses do face some higher risks due to vanishing twin syndrome, such as preterm birth and growth restriction.
The new code sets for vanishing twin syndrome specify the trimester, with O31.40X0-O31.40X9 as the unspecified trimester option. O31.41X0-O31.41X9 identifies the first trimester, O31.42X0-O31.42X9 identifies the second trimester, and O31.43X0-O31.43X9 identifies the third trimester. Our seventh-character values identify the fetus affected. 0 is the value for not applicable or unspecified, 1-5 identify fetuses 1-5 and 9 identifies other fetus. For example, vanishing twin syndrome affecting the first fetus in the second trimester would be assigned O31.42X1, Continuing pregnancy after vanishing twin syndrome of one fetus or more, second trimester, fetus 1.
Looking at ICD-10-PCS, there are several new codes identifying vein bypass using autologous cell seeded tissue. Code X2K00FB, Bypass Inferior Vena Cava using Autologous Cell Seeded Tissue Engineered Resorbable Scaffold to Pulmonary Artery, Open Approach, New Technology Group 11. This is a tissue-engineered conduit for children with single-ventricle congenital heart disease.
The scaffold bypass connects the inferior vena cava to the pulmonary artery. It is biodegradable and uses autologous bone-marrow cells. One exciting note is that this will potentially grow with the child. This procedure is investigational and not commonly used, but certainly has the potential to be an amazing technology for such patients. The second new code is X2KG0FB, Bypass Hepatic Vein using Autologous Cell Seeded Tissue Engineered Resorbable Scaffold to Pulmonary Artery, Open Approach, New Technology Group 11. This identifies the same technology, acting as a conduit, bypassing the hepatic vein to the pulmonary artery. This would also be used in treating congenital heart disease.
The Final Rule doesn’t just identify new codes; it also identifies codes that have been deleted or have had revisions. The next code today, XW0V0P7, has been revised. Currently, this code description is Introduction of Antibiotic-eluting Bone Void Filler into Bones, Open Approach, New Technology Group 7.
As of October 1, XW0V0P7 will be revised: Introduction of Gentamicin-eluting Bone Void Filler into Bones, Open Approach, New Technology Group 7. The change here is the added specificity of Gentamicin, rather than simply an antibiotic. As part of the new code additions for Oct. 1, we have XW0V0BC, Introduction of Vancomycin-eluting Bone Void Filler into Bones, Open Approach, New Technology Group 12.
So, with the code addition and code revision, we are now able to specifically assign for both Gentamicin and Vancomycin, rather than just simply antibiotic.
With just days until Oct. 1, make sure you and your coding team are ready with all the new codes and revisions. Check out the FY 27 IPPSPALOOZA for all the vital ICD-10-CM, PCS and MS-DRG information you need to know!
FY 2027 IPPS Final Rule Home Page | CMS
This article was originally published on RACmonitor.
September 10, 2026
As UnitedHealth Group continues to chart a turnaround from a challenging 2025, the company’s top brass is pulling back the curtain on those efforts at its healthcare services unit, Optum Health.
This article was originally published on Fierce Healthcare.
September 3, 2026
Medicare Part D plans made millions in payments for drugs that were ineligible under the program, according to a new federal audit.
This article was originally published on Fierce Healthcare.
Author: Veronica Richardson, MHA, RHIA, CHPS, CHC, Senior Compliance Consultant | September 2, 2026
Across the healthcare industry, the use of artificial intelligence (AI) has been growing exponentially. It’s changing the way medical records get reviewed, the way claims get scrutinized, and even the way clinical documentation gets written in the first place.
Payers, regulators, and provider organizations alike have begun leaning heavily on artificial intelligence, not as some futuristic concept, but as a working tool, already embedded in day-to-day operations. Many of our colleagues have discussed the surging impact this has had for regulatory oversight. On the data side, AI is being used to comb through massive volumes of claims and clinical data, flagging billing pattern outliers and quickly identifying deviations in a provider’s own practices, not just utilization that stands out from a peer group. This level of data analysis and auditing is at a scale human teams simply could not match working alone. What used to take analysts weeks of manual chart reviews and spreadsheet cross-referencing can now happen in a fraction of the time.
AI isn’t just analyzing data anymore, it’s stepping directly into the documentation process. In hospitals and behavioral health settings, AI‑powered tools are now acting as clinical scribes, listening to encounters and producing draft notes in real time. Others work behind the scenes as documentation improvement partners, scanning a finished note and flagging spots where more clinical detail or specificity could strengthen it.
The appeal is obvious. Provider burden, especially the late‑night “pajama time” clinicians spend finishing notes, remains one of healthcare’s biggest pain points. Tools that shave even a little off that workload feel like a win. And when those same tools help nudge documentation toward more complete, clinically grounded narratives, there’s hope that they also support something bigger: documentation that meets medical necessity standards. Given that medical necessity drives most reimbursement decisions and fuels most audit findings, that’s no small promise.
But there’s a cautionary thread running through all of this. As AI becomes more embedded in documentation workflows, organizations can’t afford to treat its output as plug‑and‑play. Drafts generated by AI still require solid clinical review — not just for accuracy, but to ensure the record reflects the provider’s actual clinical judgment. Without that oversight, the convenience of AI‑assisted documentation can quickly become a compliance risk rather than a relief.
So, on the surface, this looks like a win on two fronts — stronger documentation upstream, and smarter auditing downstream. Efficiency for compliance teams. Relief for clinicians. Better-supported claims.
However, healthcare compliance professionals will tell you this is where the real conversation begins, efficiency and volume are only part of the picture. As these tools move beyond simple data mining and start making judgment calls about clinical content itself, a new and more complicated set of questions emerges. Who’s checking the AI’s work? How much should organizations trust a finding that was generated without a human ever laying eyes on the chart? And what happens when the technology’s speed outpaces an organization’s ability to respond to what it’s uncovering?
A growing number of AI solutions on the market aren’t just analyzing claims data anymore. They’re going further, reading the documentation narrative itself, evaluating clinical appropriateness, assessing medical necessity, and checking whether a note meets documentation standards well enough to be considered complete and compliant. In effect, some of these tools are positioning themselves to take on work that has traditionally belonged to trained compliance auditors and quality assurance reviewers.
That’s a significant leap and an extremely appealing sale. And it’s why healthcare leaders are being urged to bring a discerning eye to these solutions rather than treating them as a plug-and-play replacement for human expertise. Because, like any AI-generated content, these findings can be wrong. That’s not a hypothetical caveat — it’s a documented reality of how these systems work. And it’s why the phrase you hear over and over in this space is “human in the loop.”
That phrase carries two distinct responsibilities. First, human auditing professionals need to be reviewing the findings AI tools produce — checking that those findings actually align with industry standards, applicable regulations, and the internal policies of the specific practice being reviewed. An AI model trained on general patterns doesn’t automatically know the nuances of one organization’s policy manual, or a particular payer’s contractual requirements.
Second — and this is a point worth sitting with — the efficiency of AI creates a genuinely attractive alternative to a traditional audit team reviewing a modest sample of progress notes. However, turning an AI solution loose to audit larger samples doesn’t just mean more coverage. It can mean more risk. There’s a saying in compliance circles that captures this perfectly: If you look, you find. And if you find, you must treat! Every finding an AI surfaces create an obligation. More findings, faster, means more obligations landing on an organization’s desk than it may be prepared to handle.
That risk multiplies with the newest capability entering the market — auto-feed functionality, where documentation and data flow into the AI analysis tool automatically, and results are produced essentially in real time. That sounds efficient: “Set it and forget it.” But consider the practical questions it raises. What happens with that data once it’s generated? How quickly can quality teams address clinical concerns highlighted in a chart review? How expediently can compliance professionals respond to findings — including potential overpayments — that the AI is identifying rapidly, and often continuously, on the organization’s behalf? At what point will an organization be searching for an AI agent to audit the AI auditing tool?
Organizations adopting these tools may find themselves sitting on a wealth of information they are simply not equipped to act on, or worse yet, may be playing defense against their own internally driven audit findings from a system that misses the mark. And in healthcare compliance, an unaddressed finding doesn’t just sit quietly, it becomes exposure. Under scrutiny, a backlog of unresolved audit findings makes it nearly impossible to argue that the organization “didn’t know” or “could not have known.”
So what’s the path forward? Industry voices are converging on a consistent answer: start small. Trust, but verify. Strategically select samples of data and documentation for review rather than defaulting to full-scale, automated audits from day one. AI is not leaving healthcare auditing anytime soon. The question every organization now must answer is whether their people, processes, and risk management resources can keep pace with what the technology can find.
This article was originally published on RACmonitor.
September 2, 2026
Thyme Care landed a series E financing round of more than $125 million backed by strategic payers and providers as it aims to expand beyond cancer care navigation.
This article was originally published on Fierce Healthcare.
September 1, 2026
Public comments for the latest OPPS proposed rule saw several major hospital groups all but threatening a court showdown over CMS’ planned policy changes.
This article was originally published on Fierce Healthcare.
September 1, 2026
UnitedHealthcare said earlier this year that it was aiming to eliminate 30% of prior authorization requirements by the end of 2026.
This article was originally published on Fierce Healthcare.