August 20, 2026
UnitedHealthcare is expanding access to its child and family behavioral coaching program, making it available to 13 million commercial members.
This article was originally published on Fierce Healthcare.
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August 20, 2026
UnitedHealthcare is expanding access to its child and family behavioral coaching program, making it available to 13 million commercial members.
This article was originally published on Fierce Healthcare.
Author: Adam Brenman | August 19, 2026
A federal court ruling is set to change how health plans calculate a key payment benchmark under the No Surprises Act (NSA), with implications for insurers, providers, and the law’s dispute resolution process.
Last week, the US Court of Appeals for the Fifth Circuit issued its long-awaited decision in a case called “TMA III,” following a rehearing by the full court in September of last year. The case challenged provisions of the federal government’s 2021 Interim Final Rule regulating calculation of the NSA’s qualifying payment amount, or QPA. The QPA is generally based on the median of applicable contracted rates and plays an integral role in payments and disputes involving out-of-network care.
The court largely sided with provider plaintiffs on two of three disputed elements of the QPA’s calculation methodology: the so-called “ghost rates” and certain bonuses, incentives, and other payment adjustments, while upholding the government’s approach on a third issue involving inclusion of single-case agreements.
Ghost rates are contracted rates for services that a provider doesn’t actually perform or may never provide. As an example, a contract containing a rate for a service outside a provider’s normal practice. Under the challenged methodology, such rates could be incorporated into the median used to determine a QPA. The court concluded that these rates cannot be included merely because they appear in a contract.
From a provider perspective, including ghost rates can artificially lower QPAs because providers have little incentive to negotiate meaningful rates for services they don’t perform. The court’s decision could therefore result in some higher QPAs by removing those rates from the calculation. Providers have also argued that inaccurate benchmarks can influence reimbursement offers and arbitration outcomes connected to the NSA’s IDR process.
The ruling also addressed bonuses, incentives, and other payment adjustments – something the federal methodology had categorically excluded from QPA calculations. But the Fifth Circuit found that approach unlawful, concluding that applicable compensation must be accounted for when necessary.
For health plans and federal regulators, the ruling presents a different set of considerations. Changing the QPA’s calculation methodology would force plans to modify QPAs as well as current systems and processes. Federal officials warned the court of exactly this – that vacating, or removing, the challenged rules would require extensive recalculations. However, the court determined that vacating the provisions would not be unduly difficult and indicated that agencies could temporarily permit plans to continue using existing QPAs while new amounts are calculated, as they did while the case was pending.
Now, keep in mind, the decision was not a complete victory for providers. The Fifth Circuit upheld the exclusion of one-off, single-case agreements from QPA calculations. These agreements can involve atypical reimbursement arrangements, and their inclusion could increase benchmarks beyond what an insurer typically pays for an in-network service.
Additionally, to add a bit of context, the ruling arrives as the NSA IDR arbitration system has taken on a much larger role than initially anticipated. The Centers for Medicare & Medicaid Services (CMS) and various news outlets have recently noted that providers prevail in more than 80 percent of resolved disputes, highlighting the significance of the benchmarks used during the dispute process.
The longer-term effects of the ruling remain uncertain. The overturned provisions of the QPA calculation methodology concerning ghost rates and bonuses and incentives have been vacated, leaving a void, and CMS has already said it anticipates issuing updated guidance shortly.
In the immediate future, the impact may be limited because existing plan QPAs likely will continue being used temporarily. But over time, recalculating QPAs to align with the court’s ruling may affect how both plans and providers approach the federal arbitration process.
As CMS considers its next move, stakeholders should be watching closely to determine how all this impacts reimbursement, dispute resolution, and further implementation of the NSA.
References:
This article was originally published on RACmonitor.
Author: Timothy Powell, CPA, CHCP | August 19, 2026
Artificial intelligence companies developing healthcare revenue-cycle tools need large volumes of real claims data. Two of the most valuable sources are the 837 electronic claim and the 835 electronic remittance advice.
The 837 reports what the provider billed. The 835 reports how the payer adjudicated that claim, including payments, denials, adjustments, deductibles, and coinsurance. When properly matched, these transactions can help train AI to identify underpayments, predict denials, estimate collectability, and recognize payer behavior.
Where Can AI Companies Obtain the Data?
The most practical sources are organizations already authorized to receive and maintain the transactions:
An AI company can contract with one of these organizations to develop or operate a defined application. Because the work may involve creating, receiving, maintaining, or transmitting protected health information (PHI), the AI company will frequently be a business associate.
The parties must execute a business associate agreement (BAA) specifying the permitted uses of the data, required safeguards, approved subcontractors, breach-reporting responsibilities, and what happens to the information when the engagement ends.
A BAA is Not Permission to Build any Model
Signing a BAA does not give an AI company unlimited authority to use a hospital’s claims.
If an AI vendor receives PHI to identify denials for Hospital A, it cannot automatically add those claims to a general model sold to Hospitals B through Z. The use must be authorized by the agreement and permitted by the HIPAA Privacy Rule.
Contracts should address model training directly, including the following:
De-identification Creates Another Pathway
AI companies may use properly de-identified 835 and 837 data without treating it as PHI. HIPAA recognizes two de-identification methods: Safe Harbor and Expert Determination.
Safe Harbor requires the removal of specified identifiers. Expert Determination permits a qualified expert to determine that the risk of identifying an individual is very small.
Removing patient names is not sufficient. Claims may contain medical-record numbers, claim-control numbers, subscriber identifiers, service dates, addresses, free-text fields, rare diagnoses, and unusual combinations of procedures.
Safe Harbor may also eliminate dates needed to train timely-filing or payment-delay models. Expert Determination may preserve more useful relationships while still reducing re-identification risk.
Limited and Synthetic Data
A limited data set is not fully de-identified. It remains PHI, requires a data-use agreement, and may be used only for specified purposes such as research, public health, or healthcare operations.
Synthetic 835 and 837 files provide another option. They are useful for teaching transaction structure and testing software, although they may not accurately reproduce real payer behavior.
The Correct Division of Responsibility
AI companies can obtain claims data through carefully defined provider, payer, clearinghouse, or revenue-cycle relationships. They can also license properly de-identified data or generate synthetic transactions.
The essential rule is simple: standardized data is not public data. Permission to process an 835 or 837 for one customer is not necessarily permission to use it to train a commercial AI product.
Healthcare organizations must control the data, legal agreements must control its use, and AI companies must design their models around those limitations.
This article was originally published on RACmonitor.
August 18, 2026
Satisfaction with Medicare Advantage plans has declined for the second straight year as enrollees expect insurers to be more of a partner in their care, according to a new study from JD Power.
This article was originally published on Fierce Healthcare.
August 18, 2026
The organization said the agency responded to its concerns about payers’ implementation of the transparency provisions of the 2024 final rule.
This article was originally published on Fierce Healthcare.
August 18, 2026
Humata’s AI-powered solution has allowed physicians to achieve a 96% first-pass approval rate while reducing write-offs by 30%, executives say.
This article was originally published on Fierce Healthcare.
August 17, 2026
UnitedHealthcare, Network Health and Aetna are among the first group of health plans to go live with the API, while Ochsner Health, Froedtert ThedaCare Health, Denver Health and Summit Health are the four health systems now using the real-time prior auth checks.
This article was originally published on Fierce Healthcare.
Author: Cheryl Ericson, RN, MS, CCDS, CDIP | August 17, 2026
Few diagnostic categories draw more denial activity right now than kidney diseases. Acute kidney injury (AKI), acute tubular necrosis (ATN), and chronic kidney disease (CKD) each carry their own documentation traps.
Payers have become fluent in exploiting the gaps between them to support issuing a denial. What makes this particularly frustrating is that there is clinical agreement on how to identify these conditions and clear coding guidelines, but AKI and ATN remain auditing targets.
The Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline remains the operative definition of AKI, and it is deliberately simple: a serum creatinine rise of at least 0.3 mg/dL within 48 hours, a rise to at least 1.5 times baseline within 7 days, or urine output below 0.5 mL/kg/h for 6 hours. Any one of the three is sufficient. However, I continue to see payers argue that AKI criteria “do not apply” until a patient has been adequately rehydrated, effectively demanding that the diagnosis prove itself twice.
This conflates two separate clinical questions. Whether AKI was present at the moment the criteria are met is not the same question as which subtype of AKI the patient has: prerenal, which codes to AKI, or intrinsic injury such as ATN. KDIGO criteria do not require these values to persist after fluid resuscitation before the diagnosis of AKI is valid. Fluid resuscitation is the primary treatment for AKI, which requires supportive measures and the avoidance of nephrotoxins.
A rapid, complete response to fluids does not retroactively erase kidney injury; it identifies the injury as prerenal rather than intrinsic (i.e., ATN). That distinction matters clinically, and it belongs in the documentation, but it is a question of etiology, not of whether the diagnosis of AKI or ATN is valid.
ATN, also referred to as acute tubular injury (ATI), is a form of intrinsic (renal) AKI that is characteristically persistent (AHA Coding Clinic 2nd Quarter 2026 p. 5). True ATN takes 72 hours or longer to resolve even with adequate fluid resuscitation because the sloughed tubular epithelium must regenerate. That is a real, evidence-based way to differentiate AKI from ATN. Because kidney biopsy is rarely pursued clinically, there is no true non-invasive gold standard for diagnosing ATN.
The most effective non-invasive strategy for identifying ATN is the Perazella-Coca urine sediment scoring system (Perazella et al., Clin J Am Soc Nephrol, 2008;3(6):1615-1619), in which a score of 2 or higher (based on granular casts and renal tubular epithelial cells) is described as an extremely strong predictor of ATN, carrying a positive predictive value of 100 percent in patients with a high pretest probability of the diagnosis. However, this is a manual process that is rarely performed because most hospitals rely on automated urine analyzers, which are poorly suited to identifying granular casts and renal tubular epithelial cells.
A nephrologist’s manual read of the urinalysis can reach the correct diagnosis of ATN over 90 percent of the time compared with just 19 percent when relying on the standard automated lab report. In practice applying this scoring system reliably requires a nephrology consultation and a clinician willing to personally examine the sediment, which is not something a treating hospitalist can expect from a routine urinalysis.
All of this to say that when appealing a denial for ATN, CDI professionals should push back if the payer cites a lack of cellular evidence, including muddy brown casts. Research has also shown that these casts may be absent in up to 30% of patients with ATN. The absence of cellular evidence should never be used to exclude the diagnosis of ATN.
CKD presents a different kind of documentation discipline. Per the FY 2027 ICD-10-CM Official Guidelines, Section I.C.14.a.1, CKD must be staged 1 through 5 or documented as end-stage renal disease (ESRD), and that stage must come from the provider, not from a coder or CDI specialist reading a GFR off a lab report. Coding CKD without a stage understates how sick the patient is, but documentation of “chronic renal insufficiency” is worse. If the provider were to drop the word “chronic,” the term maps to N28.9, which is not even a CKD code.
Where this gets genuinely interesting is the boundary between Stage 5 CKD and ESRD. Both describe a GFR under 15 mL/min. The difference on paper is whether the patient requires ongoing dialysis. N18.5 is reported for Stage 5 without dialysis, but N18.6 plus Z99.2 (Dependence on renal dialysis) for ESRD. But this is not merely a coding nuance; it is a Medicare eligibility trigger. Under Section 226A of the Social Security Act, a documented diagnosis of ESRD certified on the CMS-2728 Medical Evidence Report allows an individual of any age to become entitled to premium-free Medicare Part A.
If a patient has started maintenance dialysis, the documentation should reflect ESRD, not “Stage 5 CKD,” and CDI professionals should understand why that distinction carries weight well beyond the inpatient claim.
It is also possible for a patient to have both CKD and AKI superimposed on it. However, there is no “acute on chronic renal failure” combination code in ICD-10-CM. Per Guideline I.C.9.a.2 and I.C.9.a.3, when hypertensive CKD and acute renal failure are both present, the acute renal failure must also be coded, sequenced according to the reason for the encounter.
Another common argument is that a patient cannot have AKI in the setting of ESRD because these patients are unable to produce urine. ESRD is defined by GFR/dialysis-dependence, not by anuria. Per the United States Renal Data System (USRDS) only 15% of patients starting dialysis in 2020 had an eGFR below 5 mL/min/1.73m². The substantial majority of those with ESRD retain meaningful residual kidney function that can range from oliguria to normal urine output levels. However, elevated lab values in the setting of ESRD do not equate to AKI if the patient has missed or was unable to complete their regular dialysis schedule. This scenario is associated with fluid overload (and hyperkalemia) not AKI.
AKI on ESRD requires a new insult to the kidneys (e.g., infection, hypotension, nephrotoxic exposure, obstruction) that worsens the patient’s residual function or urine output from their individual baseline. This is why KDIGO’s definition requires a change from the patient’s baseline, whatever that baseline is. CDI and coding professionals can use past serum creatinine levels to try to establish a baseline if the patient has frequent visits to the facility when querying the provider for clarification.
What ties all this together is not clinical complexity; it is discipline in going back to the primary source rather than accepting a payer’s paraphrase of it. KDIGO says what it says about fluid resuscitation. The Official Guidelines say what they say about staging and dual coding. CMS’s own ESRD entitlement provisions say what they say about who qualifies for Medicare and why.
When a denial letter reinterprets any of these, the correct response is not a clinical argument about the patient’s course; it is the guideline’s actual language, quoted back. Renal disease coding will keep drawing scrutiny as kidney diseases continue climbing in the Medicare inpatient volume.
The programs that hold their ground will be the ones that treat the primary sources as non-negotiable, not the ones that quietly adjust their documentation and coding to satisfy the payer.
This article was originally published on RACmonitor.
Author: Christine Geiger, MA, RHIA, CCS, CRC | August 17, 2026
As this summer comes to an end, we look forward to the cooler weather of fall. Oct. 1 is right around the corner. Before you grab that first pumpkin spice latte, make sure you and your coding team are aware of the changes in the fiscal year (FY) 27 Inpatient Prospective Payment System (IPPS) Final Rule.
Here is a big picture overview to give you some ideas of what you need to know.
For the ICD-10-CM codes, we had 190 code additions and 30 code deletions. We also had three new major complication comorbidity (MCC) condition additions for pulmonary mycetoma, prevesical abscess and other pelvic abscess. If you do obstetric coding, you will want to review the new code sets for specific types of ectopic pregnancies.
There are also have new codes covering all trimesters for vanishing twin syndrome. There is a new code for gender identity disorder in remission as well as new personal history codes identifying various stages of gender transition.
Coders also need to be aware that we had an expansion of the low body mass index (BMI) value code, Z68.1. Two new codes now identify a BMI value of 18.4 or less or 18.5-19.9. These new codes will remain CC conditions.
For the ICD-10-PCS codes, there are 101 new code additions and 38 code deletions. There isa new code set for procedures for division of the aortic or mitral valves. There are also new spinal fusion codes that identify the use of custom-made anatomically and virtually designed interbody fusion devices. We also have new codes for procedures involving the use of an Impeller pump, new wound management modalities, as well as several new computer-aided technologies. There are new codes for urinary filtration using selective cytopheretic that will be non-OR procedures affecting the MS-DRG assignment.
Looking at the FY27 new technologies, it is important coders know which ones are discontinued, which previous ones are still considered new and which ones have had add-on payments approved for this fiscal year. Prior to the Oct. 1 implementation, which is only a few weeks away, coders should review these lists.
This is vital to educate themselves and their team on which codes to be assigning to ensure to capture that additional payment. Remember these new technology add-on payments (NTAPs) are in addition to the MS-DRG reimbursement. ZEVASKYN, one of this year’s approved new technologies, has an add-on payment of more than two- million dollars!
Don’t forget about the MS-DRG changes of which all coders need to be aware. This year there are changes in MDC 05, 08, 10, 11, 12 and 13. Two new MS-DRGs were created for hip or knee procedures with periprosthetic joint infections. Other changes involve extensive or complex spinal fusions, cardiac pacemaker revision or replacements and prostatectomies.
Also important to note, the annual review of procedure codes in DRGs 981-983 and 987-989 did not identify any cases needing reassignment. These are those extensive and non-extensive OR procedures unrelated to the principal diagnosis DRG sets.
There was a severity level change for homelessness, inadequate housing and housing instability Z59 codes. As of Oct. 1, these will no longer be considered CC conditions. Discussion in the final rule noted a similarity to the analysis of chronic illness diagnoses, further noting that a change of CC designation should be based on the expected resource use associated with the treatment of an underlying medical condition or illness rather than a patient’s social circumstances.
This is just a sampling of what changes are found in the FY27 final rule. Coders only have a couple of weeks to review and prepare.
Make sure you and your coding team are informed and ready to go on Oct.1
This article was originally published on RACmonitor.
August 14, 2026
The man accused of murdering UnitedHealthcare CEO Brian Thompson has pleaded guilty in the federal trial against him, per media reports.
This article was originally published on Fierce Healthcare.