November 9, 2026
HealthTap is rolling out a new program for Medicare Advantage plans that seeks to help members form a connection with a primary care doctor that carries forward.
This article was originally published on Fierce Healthcare.
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November 9, 2026
HealthTap is rolling out a new program for Medicare Advantage plans that seeks to help members form a connection with a primary care doctor that carries forward.
This article was originally published on Fierce Healthcare.
Author: Juliet Ugarte Hopkins, MD, ACPA-C | November 9, 2026
No matter how skilled your physician advisors and utilization management team may be, your patient status efforts will not succeed unless you actively educate the medical staff.
Under the Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 412, Subpart A, § 412.3, an Inpatient order must be provided by a practitioner who has admitting privileges and is “knowledgeable about the patient’s hospital course, medical plan of care, and current condition.” If, based on the “patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event,” the practitioner anticipates that the patient will require hospital care spanning two midnights, Inpatient status is supported. Nowhere in this rule does it say that a utilization review nurse can review laboratory and imaging results, ordered and administered medications, and incomplete physician notes, and then recommend a specific status order for the admitting attending physician.
Yes, collaboration among the utilization review nurse, a physician advisor when appropriate, and the attending physician is often a key part of the process for assigning hospitalized patients to the correct status. Even before that collaboration occurs, however, the initial key to success is ensuring that the attending physician has a solid understanding of the Medicare Two-Midnight Rule and knows how to apply it.
Physicians did not attend medical school to learn the business of medicine. They went to learn how to care for patients; to diagnose, treat, and alleviate illness. However, the days when physicians could turn a blind eye to matters outside direct clinical care are long over. When the Centers for Medicare and Medicaid Services (CMS) put the Medicare Two-Midnight Rule into effect just over 13 years ago last week, it essentially mandated clinician education on the Rule. Yet, 13 years later, I continue to work with hospitals and health systems across the country that have failed to provide this training.
Set aside MCG and InterQual criteria: your physicians do not need to be versed in them, although your physician advisors should be. The intricacies of assigning status to commercial and Medicaid patients should remain with utilization review nurses; clinicians need only understand that utilization managers will routinely contact them when those patients require a status change. What I want the admitting and attending medical staff to know is the Two-Midnight Rule. According to CMS, this education is not optional, and hospitals should recognize it as a compliance issue.
The foundational elements of the Two-Midnight Rule that should be taught include the following:
Physicians and advanced practice providers (APPs) who should receive this education include anyone who could be responsible for a patient’s hospitalization. The initial and most concentrated educational effort should begin with the following groups:
The best method for disseminating this education depends largely on the size of the hospital, the structure and scheduling of departmental meetings, and the number of physician advisors available to provide the training. Smaller and mid-sized hospitals may find that offering several in-person or virtual presentations allows clinicians to choose the dates and times that work best with their schedules. Larger health systems may benefit from creating recorded modules that medical staff can watch on demand. In every setting, after a comprehensive effort to educate existing clinicians, the organization should establish a plan to ensure that the material is incorporated into the onboarding process for all new medical staff members going forward.
Not to overlook my pediatric colleagues, these concepts apply to children’s hospitals and to hospitals with large pediatric and neonatal populations as well. The Medicare Two-Midnight Rule will not be the focus in those settings, but the applicable state Medicaid rules governing patient status certainly should be. Comprehensive, detailed clinician documentation is important across all patient populations to support appropriate reimbursement and avoid medical-necessity denials, but I believe it is even more critical for pediatric patients. Children may arrive at the hospital on death’s door and then, almost miraculously, recover quickly after receiving excellent medical care, allowing discharge within a day or two. Because of these common “rapid recoveries,” children’s hospital claims are notoriously denied for Inpatient status.
Neonatal Intensive Care Unit (NICU) statusing should not be overlooked, either. Because the appropriate level of care must be established day by day based on the baby’s condition and treatment needs, consistent and precise categorization is essential. If you are a physician advisor at a hospital with a NICU and are not involved with this patient population, now is the time to begin asking questions. In my travels across the country, this is yet another service gap I frequently encounter in physician advisory services and utilization review. Claims involving these tiny patients can leave a serious dent in a hospital’s finances: NICU care is extremely expensive, and the corresponding denials are equally costly. Just as adult intensivists should understand the connection between their documentation and hospital reimbursement, neonatologists should understand that connection as well. If particular documentation elements support a higher level of statusing but are often missing, those points should also become a focused area of education for these physicians and providers.
This article was originally published on RACmonitor.
November 6, 2026
Humana beat the Street for both earnings and revenue in the third quarter. The company reported $162 million in profit and $41.2 billion in revenue for Q3, both of which surpassed analysts’ predictions, per Zacks Investment Research.
This article was originally published on Fierce Healthcare.
November 5, 2026
Cigna is the latest health insurance company to boost its guidance for the year on the back of its Q3 results.
This article was originally published on Fierce Healthcare.
Author: Knicole C. Emanuel Esq. | November 4, 2026
For many providers, the first sign of trouble is a records request from a Medicare contractor. Recovery Audit Contractors, (RACs) are private firms hired by the Centers for Medicare & Medicaid Services (CMS) to find and correct improper fee-for-service payments. They work alongside Medicare Administrative Contractors (MACs), which process claims and conduct their own medical reviews, and Unified Program Integrity Contractors (UPICs), which focus on suspected fraud and abuse.
RACs are paid a percentage of what they recover. Contractors can also extrapolate errors in a small sample across thousands of claims, producing seven-figure demands. Many denials, however, are reversed on appeal.
The Story: In Home Health, LLC v. Kennedy
In Home Health, a hospice provider, faced a demand for roughly $1 million after Medicare contractors denied hundreds of its claims. The MAC concluded that many patients did not meet the definition of “terminal illness” in a local coverage determination. The denials were upheld by a Qualified Independent Contractor and then by an administrative law judge (ALJ).
Beyond arguing that each patient qualified, the hospice invoked Section 1879 of the Social Security Act, the “limitation on liability” provision, which protects a provider that reasonably believed a service would be covered. The ALJ rejected that defense because the hospice knew about the governing Medicare notice on hospice standards.
On July 27, 2026, the U.S. Court of Appeals for the Sixth Circuit held that the ALJ applied the wrong test. The question is whether the provider reasonably interpreted the rules, not whether it knew them. In the court’s words, if a provider “reasonably – albeit incorrectly” read the Medicare standards as covering a claim, “the safe harbor saves them from liability.” The court sent the case back to the ALJ to apply that standard.
Two cautions apply. The win is a remand, not a final victory, and the decision binds only federal courts in Kentucky, Michigan, Ohio, and Tennessee.
Key takeaways:
Conclusion: Best Practices
Begin with documentation. Answer every Additional Documentation Request completely and on time, making sure the records clearly support medical necessity. When a RAC issues an adverse finding, use its informal discussion period. The RAC may reverse itself if you send additional records.
Then calendar the deadlines carefully:
Finally, bring in counsel early, especially for extrapolated demands or any sign of a fraud referral. Medicare audits can be won, but usually only by providers who build the record, respect the clock, and are prepared to take the fight to an independent judge.
This article was originally published on RACmonitor.
November 4, 2026
Avanlee Care helps MA plans and other organizations engage caregivers within their member populations, enabling them to take action and measure what happens as a result.
This article was originally published on Fierce Healthcare.
November 4, 2026
CVS Health is splitting up. The healthcare giant announced Wednesday morning that it would divide its business units into two companies.
This article was originally published on Fierce Healthcare.
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.