The Risk of Declining Reimbursement
The most recent Kodiak Insight, titled Top Risks 2025, discusses the top 10 risk areas for healthcare provider organizations, as compiled by their risk and compliance team, from client audits. Among the highest-risk areas are finance/accounting and the hospital revenue cycle.
Unfortunately, many hospital leaders and revenue cycle leaders continue to use a legacy approach to clinical documentation integrity (CDI) and coding, one that is dependent upon case mix index (CMI) and complication and comorbidity (CC) and major CC (MCC) capture rates. READ MORE
Phasing out the Inpatient-Only List: Changes Needed for Utilization Review
Beginning in 2026, the Centers for Medicare & Medicaid Services (CMS) will begin phasing out the Inpatient-Only (IPO) List by removing predominantly musculoskeletal and complex surgical procedures – and, in parallel, adding many of them to the Ambulatory Surgery Center (ASC) Covered Procedures List.
As these codes lose their “inpatient-only” protection, hospitals can no longer rely on the procedure itself to justify status and inpatient-level reimbursement. Instead, the expected need for hospital care spanning two midnights, supported by clinical risk and post-operative needs, is expected to be the new determinant. READ MORE
UHC Seems to Realize Its Pending Restrictions on Remote Patient Monitoring Payment Won’t Fly
Modern Healthcare reported that UnitedHealthcare (UHC) says that starting Jan. 1, it will only pay for remote patient monitoring for heart failure or hypertensive disorders of pregnancy.
Apparently, this was published in a September update to physicians, but I just learned of it thanks to the Nov. 10 Modern Healthcare article. The bulletin asserts that for conditions like chronic obstructive pulmonary disease (COPD), diabetes, and hypertension that are unrelated to pregnancy, remote monitoring is unproven, and not medically necessary. As a result, UHC will not cover it. READ MORE
Data Literacy for HIM Leaders: Turning Analytics Into Advocacy
Data has become one of the most powerful assets in healthcare, but its value is realized only when leaders possess the literacy to interpret, question, and act upon it. For health information management (HIM) leaders, data literacy is no longer a desirable skill set; it is a core leadership competency.
As revenue integrity, quality reporting, risk adjustment, interoperability, and artificial intelligence (AI) reshape the health information landscape, the ability to transform raw data into meaningful insight is essential for organizational success. Today’s HIM leader is expected not only to monitor dashboards, but to elevate the story behind the numbers, advocate for operational change, and ensure that data integrity supports both financial stability and patient outcomes. This marks a crucial evolution in the profession, with thought leaders transitioning from guardians of health records to strategic advisors who influence enterprise-wide decision-making. READ MORE