July 16, 2026
UnitedHealth Group boosted its outlook for the year on the back of $5.5 billion in profit for the second quarter.
This article was originally published on Fierce Healthcare.
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July 16, 2026
UnitedHealth Group boosted its outlook for the year on the back of $5.5 billion in profit for the second quarter.
This article was originally published on Fierce Healthcare.
Author: David M. Glaser, Esq. | July 15, 2026
It is wise to have a short checklist of things to consider when you face an audit or investigation. Whether you are addressing a civil investigative demand (CID), subpoena, search warrant, or even an audit from a Medicare Administrative Contractor (MAC), there are a few things you’ll want to consider.
The first is insurance. Even if you haven’t obtained insurance specifically targeting audits and investigations, you might already have some. Whether it’s a rider on your malpractice policy or part of your director’s and office’s error and omissions coverage, you might have something that will pay for your defense costs.
Check early, because failure to contact your insurance carrier can nullify your coverage. It is also worth considering purchasing coverage specifically for defense costs. Litigation is pricey, and insurance may let you avoid the pressure to settle, in order to avoid significant legal fees.
Make sure you take steps to preserve relevant documents. For subpoenas and other government investigations, the duty to preserve information is a legal one. While there is no requirement to preserve documents during a MAC audit, you’re going to want to make sure that any relevant information isn’t lost through some automated record-deletion protocol.
You may have some communication with a government official or consultant on file that saves you. When you’re dealing with a government investigation, you’re going to need to preserve people’s text messages. It’s a pain in the butt, but it’s important.
The next thing is difficult, but extremely important. Determine whether you’ve already been audited on the same issue. A past audit can have a couple of significant impacts. For example, I’m working with a client right now wherein the U.S. attorney’s office is conducting an inquiry on medical necessity. There are about 300 services at issue. It turns out that about 15 of them have already been audited by the government, and each claim reviewed passed its audit. I’m pretty confident that’s going to bring this investigation to a speedy conclusion.
Most systems don’t have an automated method to determine whether groups of claims have been audited, so this might be a difficult task. But if you can show records passed an audit, you are almost certain to prevail.
The other reason you want to identify past audits and refunds is that if there was statistical sampling, you’ll want to determine if claims under review were in that universe, so they aren’t recouped twice. Once again, the logistics here can be very difficult. But that doesn’t make them unimportant.
Finally, use counsel who will put up a fight. That doesn’t mean they have to be jerks; it means they have to be smart, creative, and stubborn. Some people think it’s important to hire lawyers with past government experience. While some lawyers with such experience are wonderful, some haven’t made the transition to private practice very well and will routinely defer to a government position. Other lawyers will have lots of bluster, but won’t come up with the creative argument that might win your case.
Look for a lawyer who will help you win as quietly and as economically as possible.
In light of the death last week of Bonnie Tyler, a tribute seems fitting. If you find yourself asking, “where have all the good men gone? and “where are all the gods?” or even “where is the streetwise Hercules to fight the rising odds?” you don’t need to hold out for a hero. You just need really solid preparation.
This article was originally published on RACmonitor.
July 15, 2026
Elevance Health is kicking off another round of quarterly earnings results for major insurers, posting $1.5 billion in profit for Q2.
This article was originally published on Fierce Healthcare.
July 14, 2026
The health department on Tuesday rebuked a report that said an embattled proposal to add pediatric gender-affirming care service restrictions to Medicare and Medicaid conditions of participation was being shelved.
This article was originally published on Fierce Healthcare.
July 14, 2026
A new interoperability initiative will begin by targeting prior authorization cases that have the “greatest potential” to reduce administrative burden and aid patients in receiving timely care, the organization said.
This article was originally published on Fierce Healthcare.
Author: Juliet Ugarte Hopkins, MD, ACPA-C | July 13, 2026
Jan. 1, 2026 marked the start of the Centers for Medicare & Medicaid Services (CMS) plan to end the Medicare Inpatient-Only list.
Most musculoskeletal procedures were removed first, with the entire list expected to be eliminated as of Jan. 1, 2028. This policy change creates a need for careful, patient-specific status determinations, rather than automatic assumptions based only on the procedure being performed.
As in 2018, when total knee arthroplasty was removed from the list, removal of a procedure does not mean that every such procedure must be classified as outpatient. Instead, the clinical team must evaluate the individual patient’s medical condition, functional needs, home situation, and anticipated post-operative course.
The points below should guide decisions to place a patient into inpatient status when the surgeon or treating clinician reasonably anticipates that the patient will require at least two midnights of hospitalization during recovery before being safe for discharge on post-operative day two or later.
If the patient has any of the following conditions or needs, inpatient hospitalization may be appropriate when the reason is clearly documented in the medical record
An expectation that the patient will require transfer to a Skilled Nursing Facility (SNF) after surgery for skilled care supports inpatient hospitalization when the documentation explains why skilled care in a facility will be needed, and why discharge home with home services will not be appropriate after surgery:
Examples include the absence of family or friends to assist at home, multiple stairs, or other unmanageable obstacles within the home environment.
CMS anticipates that these patients will not be ready for hospital discharge until post-operative day three, which allows them to use their Medicare SNF benefit for covered charges when all requirements are met.
However, the clinician still must document what services the patient is receiving while hospitalized, why the patient cannot safely discharge home, and what medical needs require a SNF setting, on a daily basis. SNF transfer for custodial needs alone will not be covered by Medicare.
Procedure-Related Factors That May Support Inpatient Status
In addition to patient-specific medical and functional risks, the anticipated complexity of the procedure and the expected post-operative course should be considered before assigning status:
o If the procedure is expected to be technically challenging or difficult because of anatomical factors unique to the patient, hospitalize the patient as inpatient and document the reasons in detail.
o If the patient is expected to require at least two midnights of post-operative care that can only take place in the hospital, hospitalize the patient as inpatient and document in detail why the patient is not expected to be medically ready for discharge on post-operative day one.
This must be a case-by-case decision based on the factors associated with the individual patient.
This cannot be a blanket assessment for all patients.
When Outpatient Status Is More Appropriate
If the patient is in relatively decent health, takes no or few routine medications, or is expected to discharge on the day of the procedure, enter a status order for outpatient care. If complications arise during the procedure or recovery period, change the status to outpatient with observation services. If the patient’s clinical condition or post-operative care needs will not allow discharge on post-operative day one, change the status to inpatient.
Key Documentation Takeaway
The central lesson is that status determinations after removal from the Inpatient-Only list must remain individualized, clinically justified, and thoroughly documented. The record should explain not only the diagnosis or risk factor, but also why that factor creates a reasonable expectation for at least two midnights of hospital-level care, why discharge home is not safe, when applicable, and what ongoing hospital services are required. Clear daily documentation is especially important when SNF placement is anticipated, because Medicare does not cover SNF transfer for custodial needs alone.
This article was originally published on RACmonitor.
Author: Christine Geiger, MA, RHIA, CCS, CRC | July 13, 2026
As the summer heat rolls on, we continue our look at the FY 2027 Inpatient Prospective Payment (IPPS) proposed rule. Continuing with Part 2 of our proposed rule preview looking at new code additions for syndromes, we first will look at Li Fraumeni syndrome with proposed new code QA1.792.
Li Fraumeni syndrome is a rare genetic condition. Like Lynch syndrome previously discussed, patients with Li Fraumeni syndrome have an increased cancer risk.
According to Cleveland Clinic, people with Li-Fraumeni syndrome have a 90 percent chance of developing at least one type of cancer by age 60, and about half develop cancer before turning 40. Cleveland Clinic also notes that female patients are highly likely to develop breast cancer.
Li Fraumeni syndrome is due to a mutation in the TP53 gene which makes a tumor suppressing protein. When the mutation occurs, the protein isn’t made allowing cells to become cancerous.
Li Fraumeni is diagnosed through genetic testing with patients requiring an ongoing schedule of cancer screening throughout their life. Patients diagnosed as children will have a different screening schedule as they reach adulthood. Research has shown these screenings do improve survival rates.
The symptoms are related to the type of cancer that develops. Li Fraumeni syndrome is linked to many different types of cancer, but there are five that are commonly seen. These five core cancers are sarcomas, breast cancer, brain cancer, adrenocortical carcinoma and leukemia. An interesting note by the Cleveland Clinic is that patients with Li Fraumeni syndrome are more likely to develop cancers caused by radiation exposure. Since these patients may develop other cancers, it is important their providers know their diagnosis when developing their treatment plans.
This will be a new Alphabetic Index entry add for Li Fraumeni syndrome, with the proposed new code QA1.792. Tabular List will add QA1.7, Inherited neoplasm predisposition syndromes involving multiple systems, not elsewhere classified, as noted last week with Lynch syndrome. We will watch to see if this is finalized in the final rule.
Next, we will look at Loeys-Dietz syndrome with a proposed new code of Q87.A. This is also proposed to be a CC condition. Cleveland Clinic notes this is a genetic condition that affects the patient’s connective tissue, mainly the heart and blood vessels, bones and joints, the eyes and the skin. Loeys-Dietz is recent, being identified in 2005 by two physicians for whom the syndrome is named. Prior to this, this syndrome may have been diagnosed as Marfan syndrome because it also affects the connective tissue.
Cleveland Clinic also identifies four main features of Loeys-Dietz syndrome. The first is aneurysms which can occur in the aorta or other arteries. Second is arterial tortuosity, most often occurring in neck arteries. Third is ocular hypertelorism which is a distinctive feature of Loeys-Dietz. The patient’s eyes are spaced wider than in normal presentation. Fourth and final is a bifid or broad uvula, where the uvula is noted to be larger than normal or split. Cleft lip and palate, clubfoot and pectus excavatum or pectus carinatum are among the other physical findings that may also be noted.
There are five different types of Loeys-Dietz based on the gene change that is present. LDS-I mainly involves craniofacial while LDS-2 mainly involves skin. These are the two most common types. LDS-III mainly involves aneurysms and osteoarthritis. LDS-IV mainly involves Marfan syndrome-like features and aortic aneurysm issues. LDS-V mainly
involves thoracic and/or abdominal aorta aneurysms. LDS is diagnosed through genetic testing with treatment being related to disease involvement.
Q87.A will be an add to Q87, Other specified congenital malformation syndromes affecting multiple systems and will be a specific Alphabetic Index entry.
Li-Fraumeni Syndrome: Symptoms, Causes & Outlook
Loeys-Dietz Syndrome (LDS): Symptoms & Prognosis
FY 2027 IPPS Proposed Rule Home Page | CMS
This article was originally published on RACmonitor.
Author: Bryan Nordley | July 13, 2026
Question:
Which telehealth provisions were adopted in the Medicare Physician Fee Schedule (MPFS) final rule for CY2026?
Answer:
ICMS finalized its proposal to permanently adopt its waiver defining direct supervision for certain services—such as pulmonary, cardiac and intensive cardiac rehabilitation—to include virtual presence via audio/video real-time communications technology. Additionally, its waiver allowing federally qualified health centers (FQHCs) and rural health clinics (RHCs) to bill for telehealth services was extended through 2026. CMS did not propose to extend its waiver allowing teaching physicians to have a virtual presence for purposes of billing for services furnished by residents in teaching settings; however, this waiver was permanently adopted in response to public comments.
This article was originally published on RACmonitor.
Author: George Kelley | July 8, 2026
Behavioral health reimbursement has become increasingly complex as government agencies and commercial payers expand their audit activity. Organizations face compliance risk in three specific areas:
Although each area has unique billing requirements, the common theme is this: precise documentation and coding protect both revenue and compliance.
Organizations that establish consistent documentation standards and conduct regular internal reviews are better-positioned to reduce audit exposure while maximizing legitimate reimbursement.
I am going to touch on these issues more closely over the course of this article, but for more detail, Panacea has prepared an ebook you can download below.
Telehealth Services
Telehealth has become a permanent component of behavioral health delivery, but the regulatory requirements continue to evolve. Telehealth visits must follow the same coding principles as in-person visits, allowing providers to bill based on medical decision-making (MDM) or total time, when appropriate. However, virtual care introduces additional documentation requirements that must be consistently addressed.
There are four primary strategies for maintaining compliant telehealth programs:
Important documentation elements required for every telehealth visit include:
Audio-only visits continue to be allowable through Dec. 31, 2027, provided that the provider is capable of conducting video visits, the patient either cannot engage with or declines video technology, and the patient is located at home. Documentation should clearly explain why audio-only services were provided.
Psychotherapy with E&M Services
Psychotherapy combined with E&M services is one of the highest-risk billing categories in behavioral health. Audits frequently result in repayment demands reaching five or six figures because documentation often fails to adequately distinguish psychotherapy services from medical evaluation activities.
Some major audit findings are:
The aforementioned ebook will provide sample scenarios and additional detail.
Collaborative Care Model
The Collaborative Care Model is a structured, team-based approach to integrating behavioral health into primary care. Successful CoCM billing depends on clearly defined participant roles and detailed documentation.
CoCMs involve three essential participants:
Patient care is supported through the use of registries and validated assessment tools, with billing reported using CPT codes 99492, 99493, and 99494.
Three common documentation errors that frequently result in payment denials or recoupments are:
So, what steps can providers take to get ahead of these issues to reduce compliance risk and maintain entitled revenues?
These steps can go a long way to ensuring that your organization is prepared to face these compliance challenges. Feel free to download the ebook for additional detail here: https://go.panaceainc.com/l/1016042/2026-06-30/6prgr/1016042/1782834013eMY6vHhs/Solving_the_Behavioral_Health_Puzzle_eBook.pdf
This article was originally published on RACmonitor.
July 8, 2026
UnitedHealthcare is rolling out a new benefit option aimed at making it easier for employers to offer more personalized wellness programs.
This article was originally published on Fierce Healthcare.