September 18, 2026
The pause that began Sept. 1 had triggered alarm bells from provider groups and prompted an appeal from Texas Governor Greg Abbott.
This article was originally published on Fierce Healthcare.
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September 18, 2026
The pause that began Sept. 1 had triggered alarm bells from provider groups and prompted an appeal from Texas Governor Greg Abbott.
This article was originally published on Fierce Healthcare.
Author: Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI | September 17, 2026
Let’s start today with a recent U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) notice about a fraudster who was paid almost $3 million by Medicare Advantage (MA) plans for durable medical equipment (DME) that was not ordered by a physician, needed by the patients, or even approved by the plan. Seriously, Medicare Advantage? You’ll pay a fraudster $3 million for DME you never approved, but you won’t pay hospitals for medically necessary inpatient admissions that meet the Two-Midnight Rule? Something is very wrong.
Next, I want to point out a major flaw in the upcoming Comprehensive Care for Joint Replacement Expanded (CJR-X) program, starting in 2028. I was trying to understand how the Centers for Medicare & Medicaid Services (CMS) was going to set the target rates for calculating savings, and realized that we are still in the baseline period for setting the target rate for the first four years of the program.
Now, why is that interesting? Well, hospitals will get to share in the savings if their 2028 spending is less than the target rate, which is calculated based on spending during a rolling period from 2023 to 2027. In other words, it is in your best interest to send as many total hip and knee replacement patients as possible to skilled nursing facilities (SNFs) and use as much home care and outpatient therapy as possible, so when January 2028 rolls around, you have lots of room to improve.
If you are working hard now to limit SNF use and optimize time receiving home care and outpatient therapy, then once the program starts, you’ll have little room to improve. And that means no shared savings for the program partners.
Now, should you game the system like this? Of course not, but CMS really needs to think about these programs that disadvantage those who are already high-performing.
Next, let me jump back to MA, this time singling out United HealthCare. They made headlines two weeks ago when they announced they were eliminating a large number of prior authorizations. Of course, they reveled in the adulation they received.
But the devil was in the details. If you went into the actual lists of procedures that will no longer need prior authorization, you will find that the lists are different for each type of plan. There are only 160 procedures coming off the MA list, with many of them relating to DME, but more than 800 coming off the commercial plan list.
They are not removing one single gastrointestinal procedure from the prior authorization list for MA patients. So, the physician office and hospital still have to determine what CPT® code is planned and check the specific list. And since the elderly need healthcare more than younger people, the burden reduction with this is less than impressive.
And finally, I direct my disappointment at both the Quality Improvement Organizations (QIOs). They are really underperforming. The first case reflecting this was an inpatient needing SNF care. The facility offered choice. Then, the second Important Message from Medicare (IMM) was delivered, the patient was stable enough to transfer, and they had an accepting facility, but the family wanted more time to visit other facilities, hoping to find a facility with private rooms. So, the patient appealed.
And the QIO sided with the patient, noting, “due to not yet finalizing a placement in an appropriate and safe SNF, it is reasonable to continue acute-care stay.”
Seriously? This facility is CMS-approved, and it can meet the patient’s needs, plus it has an open bed, but that’s not good enough for the QIO?
The hospital is submitting a complaint to CMS.
Then that same QIO denied a MA patient’s discharge appeal because although they were admitted as an inpatient, the MA plan told the QIO they were denying inpatient status, so the patient has no appeal rights. That patient was still an inpatient, and it seems inconceivable that they would lose their appeal rights every time the payer says “we won’t approve inpatient care.”
Both the provider and I have a question submitted to CMS to find out the actual interpretation.
And finally, a QIO recently sided with a patient on their discharge appeal simply because the discharge summary was not available. The patient has not yet left the hospital! How can they demand a discharge summary?
That is absolutely improper.
Yes, the rules are complex, but the QIO is supposed to be the expert and properly represent the patient. This is disappointing, to say the least.
This article was originally published on RACmonitor.
Author: Mary Inman, Esq. | September 17, 2026
The U.S. Department of Justice (DOJ) recently announced a $541.5 million False Claims Act (FCA) settlement with The Villages Health System LLC, a Florida provider group headquartered in The Villages, Florida, over allegations that it submitted invalid diagnosis codes that increased Medicare Advantage (MA) payments. The price tag of the resolution is striking. So is the alleged path the false information took.
MA plans receive monthly payments from the Centers for Medicare & Medicaid Services (CMS). Those payments are adjusted to reflect each member’s expected health costs. Diagnoses associated with serious chronic conditions can therefore increase the amount the government pays.
According to DOJ, The Villages Health submitted diagnosis codes to Humana, UnitedHealthcare, and Florida Blue Medicare plans from 2020 through 2024. The codes allegedly lacked adequate support in the medical record or were based on record amendments that were not timely, not initiated by the treating provider, or not approved by that provider. The plans then submitted the codes to Medicare, increasing government payments – and, in turn, payments to The Villages Health.
This is a familiar risk-adjustment problem with an important twist: the defendant was a provider group, rather than a MA insurer. Provider groups may share financially in risk-adjusted payments, giving them a direct incentive to make patients appear sicker on paper. That makes employees who work in coding, chart review, compliance, and finance especially important to root out such misconduct. They may see whether diagnoses are supported, questionable codes are removed, and/or warnings are ignored.
While risk-adjustment fraud cases have typically been against major health insurance plans, DOJ’s settlement with the Villages Health is notable for its size – the largest-ever FCA settlement against a provider group – and also that it is part of an increasing number of settlements DOJ is reaching with provider groups. These have included agreements with Sutter Health and DaVita Medical Holdings, which were brought by our whistleblower clients, as well as with Beaver Medical Group, Seoul Medical Group, and Monogram Health.
What’s also interesting in this case, though, is that the misconduct was not exposed by a whistleblower, nor was it independently sniffed out by the government. Instead, The Villages Health used the U.S. Department of Health and Human Services (HHS) Office of Inspector General’s (OIG’s) Health Care Fraud Self-Disclosure Protocol to report this misconduct. Of course, self-disclosure does not erase the alleged liability. But The Villages received credit for prompt remedial action and cooperation.
For potential Medicare Advantage risk-adjustment whistleblowers, the practical lesson is simple: unsupported codes can create enormous exposure, even when they move through several organizations before reaching CMS. Useful evidence may include coding directives, chart-review results, audit findings, and internal communications showing how disputed diagnoses were treated.
Providers should take note. The settlement sends a powerful message that provider coding practices, not just MA organization (MAO) coding practices, remain squarely within DOJ’s healthcare fraud enforcement focus.
This article was originally published on RACmonitor.
September 16, 2026
Humana researchers found that cancer patients who received specialty pharmacy care coordination services had fewer hospitalizations and emergency department visits, along with lower medical costs.
This article was originally published on Fierce Healthcare.
September 16, 2026
The collaboration could offer customers pharmacy and vision services, food and over-the-counter benefits, pending regulatory review and approvals
This article was originally published on Fierce Healthcare.
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.