The Record Must Tell the Story Three out of every four sampled diagnoses didn’t hold up. That’s the headline from three new Office of Inspector General (OIG) audits of Medicare Advantage risk adjustment, and it should get the attention of every Clinical Documentation Improvement (CDI) specialist, coder, and compliance lead who touches a risk-adjusted claim. In Medicare Advantage, a diagnosis isn’t just a description of the patient. It’s a payment input. When a high-severity code
October 22, 2026
Hospital Readmission Penalties Are Rising: What Healthcare Leaders Should Be Reviewing Now
Hospital readmissions have long been a concern for healthcare leaders, but the latest Medicare payment adjustments are bringing renewed attention to the financial and clinical consequences of patients returning to the hospital shortly after discharge. For fiscal year (FY) 2027, the Centers for Medicare & Medicaid Services (CMS) is reducing Medicare payments to 2,334 hospitals, representing approximately 80% of hospitals evaluated under the Hospital Readmissions Reduction Program (HRRP). Of those hospitals, 244 will experience payment
October 14, 2026
Federal Independent Dispute Resolution Is Changing: Is Your Organization Operationally Ready?
The Federal Independent Dispute Resolution (IDR) process is entering a new operational phase. For health plans, providers, third-party administrators, billing organizations, and other participants, success will increasingly depend on the quality of the information exchanged before a dispute reaches arbitration. That makes Federal IDR readiness more than a legal or compliance exercise. It is also a claims-processing, data-quality, documentation, and workflow challenge. The Volume of Disputes Makes Process Quality Important Federal IDR is no longer
