November 3, 2026
The move reflects Humana’s broader strategy to improve care access through requiring fewer prior authorizations and making the process simpler when needed, executives say.
This article was originally published on Fierce Healthcare.
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November 3, 2026
The move reflects Humana’s broader strategy to improve care access through requiring fewer prior authorizations and making the process simpler when needed, executives say.
This article was originally published on Fierce Healthcare.
Author: Christine Geiger, MA, RHIA, CCS, CRC | October 26, 2026
If you have spent any time watching TV lately, you surely have been bombarded with commercials about Medicare Advantage (MA) plans. Medicare open enrollment ends on Dec. 7, so we will be seeing them for a few more weeks. I find myself listening a little bit closer each year as I creep toward that eligibility age, but I will be glad when Dec. 8 rolls around. For our Focus on Fraud this week, we will be looking at the MA Compliance Audit performed by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), centering on of UnitedHealthcare Benefits of Texas, Inc.
Published September 2026, this audit is one in a series where the accuracy of diagnosis codes MA organizations submit to the Centers for Medicare & Medicaid Services (CMS) is reviewed. This particular audit focused on 11 high-risk groups of diagnosis codes; these were identified as acute stroke, acute myocardial infarction, embolism, lung cancer, breast cancer, colon cancer, prostate cancer, ovarian cancer, sepsis, pressure ulcer, and diagnoses that are potentially mis-keyed or entered or submitted incorrectly.
As coders, when we hear that list, we easily can conceive of some of the potential challenges associated with them. It might be due to the supporting documentation, or lack thereof. Maybe the coders are unclear on cancer coding guidelines…and then there is sepsis. The bottom line is that as coders, we know the potential for inaccuracy with these diagnosis code groups.
The audit included a sample of 230 claims wherein program enrollees had a reported high-risk diagnosis in service years 2019 and 2020. UnitedHealthcare then would have received risk-adjusted payments for payment years 2020 and 2021. A total of 200 claims of this sample were related to the high-risk diagnosis groups, and 30 of the sample were those potentially mis-keyed diagnoses.
The good news is that for 58 claims of the sample of 230, medical record documentation supported and validated the reported Hierarchical Condition Category (HCC). For the remaining 172, however, either the medical records could not be located, or the documentation did not support the reported HCC.
The audit sample showed a total of $622,927 in overpayments because of the unvalidated HCCs. While that is a large number, remember, this was just the sample. Based on those results, the OIG estimated that the total overpayment based on unvalidated HCCs for 2020 and 2021 was $24,465,369. UnitedHealthcare reportedly does disagree with some of the findings, and I encourage you and your staff to review the full audit report. I have included the link to the report in my article this week.
For a further breakdown on the findings by diagnosis, the OIG notes that acute stroke codes were incorrectly submitted on 19 of 20 sampled. For the acute myocardial infarction, 17 of 20 were submitted incorrectly. Embolism codes were incorrectly submitted on 15 of 20.
On the cancer types, as a combined number, only 9 of 100 sampled were submitted correctly. Sepsis and pressure ulcer scored a bit better, with 7 of 20 incorrectly submitted sepsis codes and 5 of 20 incorrectly submitted codes for pressure ulcer.
The potential mis-keyed diagnoses accounted for 18 incorrectly submitted codes out of the sample of 30.
Whether you code MA accounts or not, I would encourage you to review the findings and identify potential problem areas, especially within the identified high-risk diagnosis groups, for which coders may need a guideline refresher or additional education.
This list is a great place to start to either perform a focused review on your team or prepare some learning opportunities.
This article was originally published on RACmonitor.
October 26, 2026
Earlier this year, UnitedHealthcare unveiled Avery, a generative AI companion aimed at supporting care coordination for its members.
This article was originally published on Fierce Healthcare.
October 26, 2026
The final rule retains most of the core objectives from the December 2025 proposal, but ONC significantly scaled back its approach, stopping short of the sweeping overhaul of the health IT certification program it initially proposed.
This article was originally published on Fierce Healthcare.
Author: Bryan Nordley | October 26, 2026
Question:
What can lead to payer denials of code 92972, and how can providers support the code through documentation?
Answer:
Although code 92972 was created to report this service, many payers are denying this code as not medically necessary or because the documentation does not contain enough information to support the use of this code. Providers are strongly encouraged to include in their procedural documentation why this service was medically necessary in addition to the PCI.
This article was originally published on RACmonitor.
October 23, 2026
Building stronger bridges between payers and providers will prove critical in addressing the biggest challenges facing healthcare: affordability and access.
This article was originally published on Fierce Healthcare.
October 23, 2026
The chair of a key House panel is pressing major pharmacy benefit managers on whether they retaliated against independent pharmacies for publicly supporting reform efforts.
This article was originally published on Fierce Healthcare.
Author: James Kennedy, MD | October 21, 2026
Medicare Advantage (MA), Medicaid (e.g., Tennessee’s TennCare program), and Patient Protection and Affordable Care Act (also known as Obamacare) plans’ monthly capitated per-member payments are heavily influenced by the quantity and quality of certain ICD-10-CM codes that are often simply passed through from provider (e.g., physician, hospital) claims to their funding sources (e.g., the Centers for Medicare & Medicaid Services/CMS, state Medicaid plans).
On Sept. 23, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a critical analysis of a UnitedHealthcare (UHC) of Texas’s MA ICD-10-CM code submission affecting their CMS Hierarchical Condition Category (CMS-HCC)-based capitated funding, estimating and extrapolating that UHC was overpaid by at least $24.4 million from 2020 through 2021.
While focusing on only this one MA plan, the OIG’s analysis impacts all payer and provider entities, including hospitals (and their own MA plans) and physicians (and their Independent Physician Associations/IPAs or Accountable Care Organizations/ACOs), whose quality and cost efficiency metrics (e.g., CMS’s Medicare Spending Per Beneficiary/MSPB or Merit-based Incentive Payment System/MIPS) rely on ICD-10-CM-applicable clinical documentation integrity (CDI) for their success.
Like UHC, physicians and hospitals are subject to the U.S. Department of Justice (DOJ) and OIG’s definition of fraud, as anyone who knowingly a) has actual knowledge of the information; b) acts in deliberate ignorance of the truth or falsity of the information; or c) acts in reckless disregard of the truth or falsity of the information, whereby no proof of specific intent to defraud is required.
Please consult the OIG’s report for details of their findings, available at https://oig.hhs.gov/documents/audit/11917/A-07-24-01215.pdf as to process how the OIG reached its conclusions and how UHC responded to their findings.
United Healthcare’s Rebuttal is Instructive
UHC’s response to the OIG report, signed by Mr. Robert Hunter, UHC’s Chief Executive Officer of Government Program, instructs us on how their government relations executives and legal counsel view the OIG’s methodology and rationale in denying government payments to their health plans, which can be mirrored when hospitals and physicians fight UHC denials over the same issues. Elements asserted by UHC include the following:
When addressing UHC’s denials of hospital and physician payments, Mr. Hunter’s response can serve as a template for writing a rebuttal, and even leveraged in testimony during a peer-to-peer session or in front of an administrative law judge (ALJ).
CDI Still Matters
Even though UHC rebutted the OIG’s findings, their audit remains instructive in how physicians, facilities, and their compliance officers must address their own internal documentation and coding policies, technologies, and personnel in advocating for CDI.
Interesting elements of this review include:
UHC requested that the OIG supply a list of what CMS-HCC-applicable ICD-10-CM codes subject to frequent mis-keying. Providers and their compliance officers can do the same through a Freedom of Information Act/FOIA request, which can facilitate their own internal audits.
Note again that UHC blamed their facilities and physicians for these inaccurate codes, as they claim that “CMS regulations do not require UHC to conduct the type of self-audits that the OIG recommends. In fact, the U.S. Department of Justice, on behalf of CMS, has stated that ‘MAOs are not required to audit every single diagnosis code they submit.’”
Consequently, since UHC absolves itself of any responsibility for what the OIG identified on this report, each facility or practice must ensure that they can defend these identified issues when accounted for, as to avoid legal liability.
Strong compliance programs mitigate potential penalties and embarrassment. Refer to the OIG’s General Compliance Program Guidance or your legal counsel for additional details.
This article was originally published on RACmonitor.
Author: David M. Glaser, Esq. | October 21, 2026
Once again, my computer search for a Centers for Medicare & Medicaid Services (CMS) Manual turned up massively outdated versions in the first hits. I was doing research that required analyzing the section of the Medicare Claims Processing Manual discussing the teaching physician rule.
I know exactly where the text is, so I typed “Medicare Claims Processing Manual Chapter 12” into the search bar. The opening lines of a Manual section show you when it was last revised.
One huge problem is that the CURRENT Manual won’t have today’s date; it will show when it was last revised, which could be recent, or it could be years ago. Nothing in the Manual text itself will verify that it is the most recent iteration.
My first search yielded text showing that the most recent changes had been made in 2024. That is certainly plausible, but I happen to know that the Manual has been revised more recently than that.
In fact, it was updated in May of this year. For whatever reason, the search engine felt that the “best” hit wasn’t the current version, but one that is two years old.
I decided to play around a little more and tried the search in different search engines and different browsers. The results were a bit inconsistent. One search resulted in the first hit being the Manual as it existed in 2011, with other attempts yielding the most recent Manual section. Then, later in the day, a search on an unrelated topic yielded the same problem.
This is a huge trap, and one without an easy fix, unless you go to the CMS website and pull the current Manuals, or have a good subscription service.
It’s worth talking about the situation that prompted this search. I’m involved in a teaching physician rule investigation. The government is pointing to Manual text that says, “In the case of three concurrent surgical procedures, the role of the teaching surgeon (but not an anesthesiologist) in each of the cases is classified as a supervisory service to the hospital, rather than a physician service to the individual patient, and is not payable under the physician fee schedule.” That seems simple enough. But it’s totally wrong.
The reason it’s totally wrong is that no such limitation appears in the regulation. In fact, 42 CFR § 415.172 says that in the case of surgery, the teaching physician’s presence is not required during opening and closing of the surgical field. Under the regulation, it is clear you can have one procedure opening, another closing, and the third in the critical portion, but the Manual suggests that is improper.
The manual invented a new requirement out of whole cloth. Longtime readers know that manuals are not binding. Remember that I was once in a case in which the federal government challenged my client’s reliance on the manuals by stating that you “rely on information in the manuals at your own peril.”
I look at the manuals all the time, because I want to know what’s in them. But no one should ever be refunding money off of something found in the manuals.
And if you are in a situation like I am now, where the government is seeking to recover money based on the manuals, you should fight back hard. If you find a requirement in a Manual, work your way back up to the regulations and statutes before cutting a check.
This article was originally published on RACmonitor.
Author: Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI | October 21, 2026
Last week Dr. Mark Spoolstra, the physician advisor at Trinity Health Grand Rapids, sent me a recent bulletin from Blue Cross of Michigan that applies to all of their Medicare Advantage (MA) products in the state.
The memo starts with the usual niceties, explaining the important role in discharge planning when patients are hospitalized, and notes that “discharge planning should begin early in the hospitalization and be reassessed as the patent’s needs change.” That makes sense, and I am sure every hospital strives to start that plan as soon as possible.
But then they go off the rails. Blue Cross states that “providers submitting an authorization request for an acute inpatient medical and surgical admission for a member will be required to include the member’s discharge planning evaluation along with the clinical information required for the request.”
They go on to describe the elements of a discharge planning evaluation, including an anticipated discharge disposition and date, the patient’s clinical needs at discharge, the patient’s functional and social needs, and the availability of post-acute care services for the patient.
This policy makes no sense. Does this payer think that case managers are lined up in the ED waiting for new patients so they can push the medical team aside and start developing a discharge plan before there is even a diagnosis or treatment plan, so they can have it ready to send with the request for approval of inpatient admission? Do they expect the case manager to call the family to talk about discharge plans for their critically ill loved one even before it is known if they will survive their acute illness, so the hospital can notify Blue Cross of the inpatient admission?
Now, I could go into the nuances of this policy and point out that not only is this requirement utterly impossible to meet, but it also has a giant loophole. If you read the policy carefully, it states that it applies to a request for “an acute inpatient medical and surgical admission.” Admissions are either medical or surgical, and not both. So, one could argue that this policy actually applies to absolutely no patient at all. But I suspect the payer will not accept that argument.
This led me to review the payer’s other policies, and there is one indicating that “When an admission occurs through the emergency room, Blue Cross Network asks that the facility contact the primary care provider prior to admission to discuss the member’s medical condition and to coordinate care prior to admitting.” It is not the role of the emergency department physician or staff to do this. Once the patient is hospitalized and stabilized, only then should such coordination begin.
Now, perhaps they are channeling the policy of another payer that expects hospitals to “coordinate the care” by ensuring only in-network providers are used, but that is far from clear from the policy wording.
I can envision a patient presenting to the emergency department with sepsis and metabolic encephalopathy, who receives patient-centered, efficient, evidence-based care, and is transferred to the intensive care unit (ICU). The notification of inpatient admission is sent and inpatient admission approval is denied due to lack of a formal discharge plan.
Two days later, now that the patient’s mental status has cleared, family is available, and they are transferred out of the ICU, a discharge plan is started, but the inpatient admission request will be denied “as the patient’s condition no longer warrants inpatient admission.”
Our country’s healthcare payment system is beyond complex, but policies such as this cannot be justified. The medical care of the patient must be prioritized.
Penalizing providers for doing such has no ethical basis and must be fought.
This article was originally published on RACmonitor.