Is the Medical Record a Clinical Tool or an Invoice?
The medical record is a clinical tool used to share valuable information with other healthcare professionals within the same and other healthcare facilities. The priority of providers when entering notes is continuity of care, not creating an invoice to support a bill, yet that is what payers have come to expect.
One of the most egregious examples of self-inflicted revenue leakage at hospitals is when leadership within the clinical revenue cycle departments (e.g., clinical documentation integrity/CDI and coding) allow payer expectations to drive organizational practices. Querying the provider to add all diagnoses classified as a complication/comorbidity (CC) or major CC (MCC) to the discharge summary is one such type of process.
Key Insights on the Use of AI in the Audit and Compliance Industry
What’s happening in healthcare today regarding artificial intelligence (AI) and auditing?
What I am seeing across the auditing landscape is the expectation that AI will become a primary auditing method and tool in the future.
With AI, we can expect less manual data entry, the ability to audit more claims or larger statistically valid samples, and more robust review processes with less effort. We are also hoping to search medical records more effectively without relying entirely on manual chart review. READ MORE
An IPPS Proposed Rule Preview – Body Mass Index (BMI)
The first proposed invalid code for the 2027 fiscal year (FY) is Z68.1, Body mass index (BMI) 19.9 or less, adult. Codes may be proposed to be invalid for a number of reasons, with one being that there are new proposed codes that offer more specificity or further clarification. That is indeed the case here. For FY 2027, Z68.1 will become invalid and will be replaced by two new codes:
Accepting Downcoded Medicare Advantage Payments: A Growing False Claims Act Risk for Hospitals
Hospitals across the country are facing mounting financial pressure from Medicare Advantage (MA) plans. One increasingly common tactic used by MA payers is systematic downcoding: paying hospitals at a lower level of care or service than was billed. While many hospitals accept these reduced payments, doing so may expose them to significant False Claims Act (FCA) and related legal risks. READ MORE