BC ADVANTAGE - May/June 2025 by Digital Publisher

FRAUD

UPSKILLING IN THE AI AGE PREPARING CODERS FOR A NEW PARADIGM

ADDRESSING WORKPLACE BULLYING IN MEDICAL PRACTICES

UNDERSTANDING INTERNAL SELF-REFERRALS

CDI-METAMORPHOSING INTO SOMETHING FAR BETTER

NOTE EDITOR’S

Happy Spring! A time for new growth. Here at BC Advantage, we have been doing just that! If you have visited the website recently (if not, you should!), you have likely noticed some new features. We have implemented these to be more engaged with you, our readers and subscribers, to help you learn the material in other ways, and to determine what you might want to learn about next!

Some of these new website features include:

• Audio: We are adding audio to online articles for auditory learners, for those who like to listen and read along, and for those who like to multitask. Just push play!

• Transcription: We are transcribing webinars to better help you find information not provided in the slides; this is especially helpful for those audio-only webinars.

Managers Knowingly Skew Audit Results,” written by Carl J. Byron, CCS, CHA, CIFHA, CMDP, CPC, CRAS, ICDCTCM/PCS, OHCC, and Retired CPT/03, USAR FA. As any system can be bypassed or manipulated and thus open to fraud, it is necessary— and possible—to detect early and avoid unintended consequences. This rich read is a two-part series—but don’t worry, you don’t have to wait until the next print issue to read part 2—catch it online at Billing-Coding.com.

• Social Media Links: These are added to online articles for you to easily click and share via Facebook, X, LinkedIn, or email. Share updates with your peers!

• Surveys: These will pop up occasionally and ask a question relevant to the field, and you will immediately see poll/peer responses. These help us identify topics that are most significant to you for future articles and webinars.

We are excited to bring each of these new features to you! Be watching for other updates to our website, print magazine, and social media this year!

In this issue, our cover is “Fraud Indicators and Red Flags: Part 1 - When Audit

Other coverlines in this issue include: “Upskilling in the AI Age” by Taylor Webster and Tricia Lewis (Fathom Health); “Addressing Workplace Bullying in Medical Practices” by Karen Blanchette (PAHCOM); “Understanding Internal Self-Referrals” by Ashley Morgan (Liles Parker); and “CDI-Metamorphosing Into Something Far Better” by Glenn Krauss (Core-CDI). Additional articles discuss new MRI safety codes, risk adjustment and HCC coding, audit results, telehealth, unveiled data, and AI in RCM, with a spotlight on Mental Health Awareness Month. These are all such timely topics!

Nichole Anderson, CPC nichole@billing-coding.com

The BC Advantage team has been working hard to bring you the topics you want— and need—to learn, to offer material in multiple formats, and to engage more with our audience. If you like what we’re doing, please leave a positive review on Facebook! If you have ideas for improvement, please reach out to us—our ears and inboxes are open! For over 20 years, BC Advantage has been here to provide resources for medical practices and the people behind them!

Amber Joffrion BC Advantage Editor

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FRAUD INDICATORS & RED FLAGS PART 1 - WHEN AUDIT MANAGERS KNOWINGLY SKEW AUDIT RESULTS

Fraud cannot be eliminated. No system is completely fraud-proof, as any system can be bypassed or manipulated. However, it can be detected early by paying greater attention to common fraud indicators. This article follows a road less-traveled by discussing the potential of audit managers knowingly skewing audit results, causing unintended consequences within what appears to be a well-functioning compliance program.

Understanding the New MRI Safety Codes for 2025

CDI-Metamorphosing Into Something Far Better

Best Practices in Risk Adjustment and HCC Coding: Ensuring Accuracy and Compliance

Walking the Tightrope: Delivering Audit Results in Healthcare with Professionalism and Precision

Understanding Internal Self-Referrals

Telehealth and Advanced Practitioner Coding Considerations

Addressing Workplace Bullying in Medical Practices: A Manager’s Guide to a Healthier Office Culture

Upskilling in the AI Age: Preparing Coders for a New Paradigm

Data Unveiled: The Impact of VBC and AI on Preventive Care and Chronic Disease Management

Healthcare Awareness Spotlight: May Is Mental Health Awareness

How Artificial Intelligence Will Help or Hinder the Medical Revenue Cycle Process

EXPERT CONTRIBUTORS THIS ISSUE

Teri Bedard, BA, RT(R)(T), CPC, is Executive Director of Client and Corporate Resources at Revenue Cycle Coding Strategies (RCCS). www.rccsinc.com

Karen Blanchette, MBA, is the Executive Director of PAHCOM. The PAHCOM collaborative network enables solo providers and small group physician practices to access focused information vital to managing their healthcare businesses effectively. https://my.pahcom.com/certifications

Betty A. Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is a nationally recognized healthcare consultant and speaker. She is an expert auditor and loves to help practices stay compliant and profitable. Betty states, “Physicians work hard for their practices and they should be paid properly for what they do.” chcs.consulting/

Dave Jakielo is President and CEO of David D. Jakielo Seminars and Consulting. Dave has over 30 years of hands-on management experience, speaking, consulting, and teaching business methods to managers, clerical staffs, business owners, and other industry professionals throughout North America, Europe, and Asia. www.Davespeaks.com

Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, C-DAM. He is the CEO and Founder of Core-CDI.com is a well-recognized & respected subject matter expert in the revenue cycle with an emphasis and focus upon collaborating and working closely with physicians in promoting, advocating for, educating

and achieving sustainable improvement in clinical documentation. Core-cdi.com

Ashley Morgan is a Partner in Liles Parker, PLLC’s Washington, DC office. Ms. Morgan represents healthcare providers across the country in connection with regulatory healthcare compliance matters, fraud and abuse, and reimbursement issues. lilesparker.com

David L. Morris is EVP and Chief Commercial Officer at Cedar Gate Technologies. He has over 30 years of operational and executive leadership experience at bluechip companies throughout the healthcare ecosystem. David drives client success across the value-based healthcare landscape by addressing the technology and service needs of the payor, provider, employer, pharma, and retail markets.

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist of SP Collaborative, LLC. Sonal has over 13 years of experience understanding the art of business medicine as a nationally recognized thought leader, speaker, author, creator, and consultant to elevate coding compliance education for the business of medicine. www.spcollaborative.net

Rachel V. Rose, JD, MBA, advises clients on compliance, transactions, government administrative actions, and litigation involving healthcare, cybersecurity, corporate, and securities law, as well as False Claims Act and DoddFrank whistleblower cases. www.rvrose.com

Taylor Webster Head of Coding Quality, and Tricia Lewis Coding Quality Advisor. www.fathomhealth.com

We are always interested in hearing from any industry experts who would like to get published in our national magazine. Email us at editorial@billing-coding.com to request a copy of our editorial guidelines and benefits.

Digital Medicine and Coding in the AMA Handbook

Three Coding Areas in the Government’s Crosshairs NEWS

The American Medical Association (AMA) has introduced new digital medicine codes for 2025 that simplify the process of coding for telemedicine services. These new codes don’t require traditional telemedicine modifiers, as telemedicine is already built into the codes. This change is part of the AMA’s effort to streamline reporting for services like audio-video visits, remote monitoring, and chronic care management.

A new AMA resource, the Digital Medicine Clinical Scenarios: Coding Handbook, provides guidance for 14 common digital medicine encounters. It details CPT coding for services such as synchronous audio-video visits, online evaluations, self-measured blood pressure, and continuous glucose monitoring. The handbook also explains how recent changes, including telemedicine-specific codes, impact reporting.

Key codes for remote physiological monitoring include:

• 99453: Setup and calibration of remote monitoring devices.

• 99454: Supplying devices and monitoring for 30 days.

• 99457: Treatment management based on remote monitoring data.

For these codes to apply, devices must meet FDA medical device criteria and be ordered by a healthcare professional. The handbook also addresses the importance of matching the correct codes with the services provided during each encounter.

Despite these changes, Medicare (CMS) is still requiring the use of traditional telemedicine modifiers. For Medicare reporting, physicians are advised to use the original outpatient visit codes with the appropriate modifiers (e.g., 95 for audiovisual visits or 93 for audio-only visits).

The AMA advises physicians to confirm coding practices with payors, as commercial payors may adopt different reporting standards.

Source: AMA

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) is focusing on three key areas related to Medicare billing:

• Lower Extremity Peripheral Vascular Procedures: The OIG is scrutinizing Medicare payments for revascularization procedures used to treat conditions like peripheral artery disease. These procedures (CPT codes 37220-37235 and 0234T-0238T) cost Medicare approximately $1.16 billion in 2022-2023. The OIG is investigating potential billing errors or fraud in these claims.

• Medicare Part C Diagnosis Documentation: Medicare Advantage (Part C) insurers receive higher payments for more complex diagnoses. However, errors in diagnosis coding have led to improper payments, estimated at 9.5% of Medicare Advantage payments. The OIG is auditing whether these diagnoses are properly supported by medical records to ensure accuracy and prevent overpayments.

• Medicare Part C Health Risk Assessment (HRA) Diagnosis Codes: The OIG is also examining HRAs used by Medicare Advantage organizations to collect enrollee health data. Some diagnoses reported in HRAs lacked supporting medical documentation, leading to inflated risk-adjusted payments. The audit aims to ensure these diagnoses comply with federal requirements.

These audits emphasize the importance of accurate documentation and coding to maintain Medicare’s financial integrity and prevent fraud.

Source: ICD MOnitor

CONSULTING SOLUTIONS

CHCS offers a variety of customized consulting solutions, depending on your specific needs.

• Compliance Program Evaluation, Denials Review, Payor Audit Rebuttal, General Office Practice Assessment, Shadowing Service

EDUCATION SOLUTIONS

Educational Services elevate your organization through targeted learning experiences that drive compliance, enhance coding accuracy, and improve overall operational efficiency.

• Webinars, Workshops, E/M Workshops, Seminars/Educational Sessions

AUDITING SOLUTIONS

Our comprehensive audit services are tailored to the unique demands of the health care sector.

•Audit Subrscription, One-Time Audit Service

CODING TOOLS

CHCS offers its suite of E/M coding tools designed to support your practice in achieving flawless coding outcomes. From robust physical tools to versatile digital solutions, we provide the resources your team needs to ensure accurate E/M service levels are consistently applied.

• Physical Coding Tools, Digital eTools

Betty A. Hovey is a seasoned healthcare professional with over three decades of experience in the field. She has extensive experience conducting audits for medical practices and payors. She specializes in educating various groups including coding professionals, auditors, doctors, APPs, payors, and others on coding, billing and related topics. Betty is a highly sought-after speaker and has co-authored manuals on ICD-10-CM, ICD-10-PCS, E/M, and various CPT specialty areas.

Understanding the 2025 Codes for new Mri safety

Magnetic Resonance (MR) safety is a critical concern due to the powerful magnetic fields and radiofrequency energy used in Magnetic Resonance Imaging (MRI) scans. The MR environment has the potential to pose significant risks to patients with implanted medical devices or foreign bodies. These objects may heat up, move, or malfunction, potentially causing harm. Prior to 2025, there was no specific way to report the extra effort involved in assessing and mitigating these risks before an MR exam or procedure. Now, providers can be reimbursed for the essential tasks required to safeguard these patients, including implant or foreign body evaluation, implant positioning or immobilization, safety consultation, and preparation of electronic devices. This change acknowledges the importance of MR safety protocols and supports the necessary steps to protect patients while maintaining imaging quality.

New MR Safety Codes for 2025

The 2025 CPT code set includes six new codes representing MR safety services. The new codes portray safety services that are beyond the standard safety screening performed for all patients receiving an MR examination, which are not reported separately. In addition, not all patients with a medical device or foreign body will need the safety services represented by the new

code set. For example, if a patient has a medical device known to be MR-safe and requires no modifications to the exam, the safety services represented by the new code set are not needed.

Patients requiring services represented by the new code set include:

• Those with a medical device or foreign body that lacks MR conditional labeling for which additional time and research are needed to determine the safety of the device.

• Those whose devices are determined to be contraindicated for the MR examination or require additional safety precautions and/or modifications to the MR examination.

As stated in the 2025 CPT Manual:

Implants may have FDA-approved labeling specifying conditions under which an MR examination could be safely performed. These conditions can specify the type of MR equipment to use, preparation of the implant before the MR procedure, anatomical regions that should be excluded from the MR examination, limitations on MR scan time and energy deposition, and/or implant components that may contraindicate MR examination.

Date of Service (DOS)

The first three codes in the series, CPT codes 76014–76016, represent MR safety services provided prior to the date of service (DOS) of the MR examination; however, exceptions can be made for emergent situations. The final three codes, 76017–76019, represent MR safety services provided on the same DOS as the MR examination.

MR Examination Not Performed

There is one MR safety code (76017) which represents MR safety services that are provided in real-time as the MR examination is being performed. Apart from CPT 76017, all other MR safety services should still be reported if the MR examination is not performed. The MR safety codes are standalone services that are separate and distinct from the MR examination.

Table 1

Safety Services on Date Prior to MR Exam

Reporting Multiple MR Safety Services

There may be instances where more than one MR safety service is needed to ensure patient safety. These codes may each be reported independently for the same MR examination. Codes 76017–76019 are modifier 51 exempt, which means there is no multiple service payment reduction when reporting all three codes for the same MR examination.

CPT Code Series 76014–76019

Following is a summary of the new codes, including recommended documentation requirements as stated in the CPT® and RBRVS 2025 Annual Symposium and clinical example summaries from CPT® Changes: An Insider’s View 2025. See Table 1.

MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (e.g., surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; initial 15 minutes.

Each additional 30 minutes (List separately in addition to code for primary procedure).

MR safety determination by a physician or other qualified healthcare professional responsible for the safety of the MR procedure, including review of implant MR conditions for indicated MR examination, analysis of risk vs. clinical benefit of performing MR examination, and determination of MR equipment, accessory equipment, and expertise required to perform examination, with written report.

Technical Component Only

Analysis and Documentation by Clinical Staff (CPT 76014 and 76015)

The first two codes in the new code set, CPT 76014 and 76015, represent the technical component for any preparatory research performed by clinical staff. These services are performed on a date prior to the MR exam, have no physician involvement or work, and do not require a modifier. After performing the necessary research for the medical device in question, the clinical staff needs to document their findings in the medical record for review by the physician and identify whether the device is MR Safe, MR Conditional, or MR Unsafe and any applicable contraindications for the MR exam.

These two codes are time-based; clinical staff should include the total time spent on research in their documentation. As time-based codes, staff must meet the midpoint threshold to support billing. For example, CPT 76014 is billed for the initial 15 minutes spent performing the analysis; if the clinical staff member spends 8 minutes, they have exceeded the midpoint threshold of time and can bill the service. If the clinical staff only spends 7 minutes, it is not billable as they did not cross the midpoint threshold time requirement. Add-on CPT code 76015 represents each additional 30 minutes of research; therefore, a minimum of 16 minutes of research must be performed in order to report the service in addition to CPT 76014. CPT 76015 can be reported a maximum of three times per encounter.

The AMA provides the following clinical example:

Clinical Example Summary: An MRI of the lumbar spine is ordered for a patient with a neurostimulator. The medical record does not include model information for the implanted leads. Certain lead models have anatomical exclusion zones over the implant. MR conditions for the implant are dependent on the lead model; therefore, clinical staff must use appropriate sources, such as a patient screening form, surgical reports, or review of prior imaging and various databases, in order to determine MR conditional status of the implanted leads. This information is documented in the patient’s medical record to be accessed by the radiologist and/or MRSO. Documentation should indicate the leads as either MR safe, MR conditional, or MR unsafe.

Analysis and Documentation by Physician or QHP (CPT 76016)

CPT 76016 represents work on a date prior to the MR exam but is performed by the physician or other qualified healthcare professional (QHP). In emergent situations, this may be performed on the day of the MR exam. The physician or QHP must document the findings and analysis in a formal written report.

This code is intended for situations where an implant and/or foreign body lacks MR conditional labeling, is contraindicated for MR, or may result in a limited MR examination based upon the performance of an MR safety determination by a physician or other QHP responsible for the safe performance of the MR procedure. If the device or implant is known to be MR safe or if the MR conditional labeling is clear or not relevant, a risk benefit analysis is not needed as they do not present a limitation to the performance of the MR exam.

The physician should assess proximity of the implanted device/foreign body to sensitive tissues and evaluate the clinical risk to the patient if device malfunction, thermal injury, or displacement forces are induced by the MR exam procedure. The MR exam parameters are reviewed for conformance with implanted device safety instructions, and if not, decide whether informed consent should be obtained prior to the MR exam. Alternative diagnostic tests are considered for appropriateness and relative risk.

The report should address the issues related to the implanted device and the MR exam. If the device is determined to be “MR Conditional,” a risk benefit analysis by a physician or other QHP responsible for the safe performance of the MR exam should be included. If it is determined that the MR exam can be conducted, additional documentation should address what needs to be scanned, the specific sequences, if the risks outweigh the benefits, and if there is any special MR equipment or expertise needed to carry out the exam.

The AMA provides the following clinical example:

Clinical Example Summary: A pacemaker lacks MR conditional labeling and programming modes. A physician or other QHP performs a risk benefit analysis, including review of MR safety parameters for conformance with implanted-device safety instructions. If MR safety parameters do not conform with the implanted-device safety instructions, the physician or other QHP will consider alternative diagnostic tests for appropriateness and risk, and make recommendations for alternative tests, procedures, or MR requirements.

In the event the MR exam is cancelled based on the findings of the MR safety review and analysis, the services related to the analysis can be billed. See Table 2.

MR safety medical physics examination customization, planning and performance monitoring by medical physicist or MR safety expert, with review and analysis by physician or other qualified healthcare professional to prioritize and select views and imaging sequences, to tailor MR acquisition specific to restrictive requirements or artifacts associated with MR conditional implants or to mitigate risk of non-conditional implants or foreign bodies, with written report.

MR safety implant electronics preparation under supervision of physician or other qualified healthcare professional, including MR-specific programming of pulse generator and/or transmitter to verify device integrity, protection of device internal circuitry from MR electromagnetic fields, and protection of patient from risks of unintended stimulation or heating while in the MR room, with written report.

MR safety implant positioning and/or immobilization under supervision of physician or other qualified healthcare professional, including application of physical protections to secure implanted medical device from MR-induced translational or vibrational forces, magnetically induced functional changes, and/or prevention of radiofrequency burns from inadvertent tissue contact while in the MR room, with written report.

Analysis and Documentation by Physician or QHP (CPT 76017–76019)

Some devices may require MR safety exam customization in real-time as the MR examination is performed. The staff performing this work would likely be the medical physicist or MR safety expert (under supervision of the physician or other QHP for CPT 76017 or qualified clinical staff for CPT 76018 and 76019). Physician supervision and physician work should be evident in the documentation pertaining to each of these codes.

The reports for CPT 76017 and 76018 should address any MR safety exam customization or changes made in real-time on the date of the MR exam. Report documentation on how the examination was customized and modified for specific patient circumstances should include a review of exam indications, analysis and any adjustment of the MR scanning protocols based on specific patient parameters and imaging requirements, and monitoring of the performance of the MR exam itself in real time. Additionally, the documentation for CPT code 76018 should address the programming performed to put the device into safe mode, or other appropriate programming, while the patient is in the MR suite and prior to the examination. If the device was put in safe mode in a separate office, i.e., outside of the MR suite in the neurologist/cardiologist’s office, CPT 76018 is not separately billable. Documentation should also address that the device was returned to normal mode following the scan, as appropriate, and signed.

The AMA provides the following clinical example for CPT code 76017:

Clinical Example Summary: An MRI is ordered for a patient presenting with new seizures and weakness. The patient has a deep brain stimulator (DBS) for Parkinson disease. The DBS has MR conditions restricting scan time and energy deposition. MR conditions of the DBS, including scanner idle times to allow for device cooling, are met by a medical physicist who customizes and monitors the performance of the MR exam interactively. The medical physicist performs these services under the supervision of a radiologist who reviews MR images and provides feedback to the medical physicist in real time to determine if any scan parameter

adjustments or additional views are needed. The radiologist considers cutting additional views from protocol in order to avoid exceeding any total scan time restrictions of the DBS. Any limitations to the MR examination that are related to the DBS system affecting the diagnostic quality and interpretation of the MR examination should be documented in a written report.

The AMA provides the following clinical example for CPT code 76018:

Clinical Example Summary: A patient with a DBS has their device modified into an MR safe mode in the MR suite prior to the exam. The device programming is performed in a safe area away from the scanner, where the patient also gets their IV started before the MR examination begins. After the MR examination is completed, the device is turned back on in a safe area, where the patient also changes their clothes.”

Some devices or implants may have the potential to migrate when exposed to the MR environment. There are manufacturer instructions on properly immobilizing the patient to keep the device from moving. For example, a patient with a cochlear implant, which uses an internal magnet that can only be removed with surgical intervention, may require a compression headwrap to mitigate the risk of the implant moving during the MR examination. Because there is a risk to the patient by exposing them to the MR environment, this service requires an informed consent discussion with the patient prior to the MR examination. CPT 76019 represents the immobilization or positioning of a device for a safer MR exam. Report documentation should include the specific device and potential to migrate, any manufacturer instructions to immobilize the device, risk to the patient and device by placing them in the MR field, and informed consent discussion with the patient before the exam.

The AMA provides the following clinical example for CPT code 76019:

Clinical Example Summary: An MRI of the brain is ordered for a patient with an auditory brainstem implant (ABI).

The ABI has MR conditions for an internal magnet, which require the application of a head wrap to immobilize and secure the device. Because there is a risk to the patient and to the ABI when entering the MR field, this service requires a discussion with the patient prior to the start of the MR examination. Informed consent must be obtained from the patient before proceeding with the MR examination.

The ABI is immobilized according to the implant manufacturer’s MR conditional instructions. The physician or QHP monitors the patient’s condition during positioning and introduction into the MR exam room. The patient is introduced and removed slowly from the MR examination. The examination is discontinued if the patient cannot tolerate the pain, after which the immobilization wrap is removed, and the ABI location is checked for any evidence of implant migration, malfunction, or tissue damage. The patient is provided with educational materials. Any implant positioning and immobilization precautions, as well as recommendations for future MR examinations, are documented in a written report.

With these updates, ensuring compliance and accurate documentation is more important than ever.

Teri Bedard, BA, RT(R)(T), CPC, is Executive Director of Client and Corporate Resources at Revenue Cycle Coding Strategies (RCCS).

www.rccsinc.com

CDI-Metamorphosing Into Something Far Better

Clinical Documentation Integrity (CDI), previously referred to as Clinical Documentation Improvement, has been a strong passion of mine for the past 27 years, predating the recognition of CDI as a profession. I am always advocating for and will continue to advocate for a radical transformational change in current CDI processes that do not lend themselves to true physician engagement as willing active participants. Active physician engagement beyond that represented by simply answering queries is necessary for an effective CDI program that noticeably moves the needle in clinical documentation with sustainability. There is a definite natural resistance to change within the profession given the comfort level of the status quo. Marked changes in CDI structure and processes are not always easy with current forces in the industry content with present CDI processes. The CDI associations and CDI consulting companies are happy with the current CDI situation since both are continuing to find the current status to be quite profitable. After all, why change if money is being made with software and consulting engagements?

In regards to CDI transformation, I recently connected with a business development professional representing a unique clinical documentation software solution. We conversed over LinkedIn, looked at the firm’s website, and were intrigued by the informational content appearing

on the website to the point I requested a demonstration to learn firsthand the solution’s functionality and capabilities. During the demonstration of the physician documentation solution, asking pertinent questions, seeking clarification, and reflecting on the information gained, it is evident that this software’s capabilities and focus upon truly assisting physicians document and chart within the EHR relegates CDI queries irrelevant and not needed. The software streamlines the physician’s ability to capture the formulation of the assessment and plan of care reflecting their clinical judgement, medical decision making, thought processes, and supportive clinical facts and clinical information leading to the diagnoses of record with appropriate clinical specificity. To one of my physician colleagues who is still practicing medicine, this is the Holy Grail to accurate and complete physician documentation, relieving him and his fellow physicians of the monkey on their back—that is, repetitive queries. The software utilizes Artificial Intelligence (AI) to scour the record to ensure no diagnosis is missed, helps physicians spend less time in the EHR, and improves the hospital’s bottom line while alleviating compliance and financial risks. No, this is not an advertisement for this physician documentation solution. Why am I providing you, the reader, with this information? Allow me to explain and outline below.

The Danger Is Real Right Now!

My contention has always been that, at some point, artificial intelligence and other sophisticated IT applications adopted to the EHR would eventually replace manual chart review by clinical documentation integrity specialists. There presently exists other documentation software solutions that purport to enhance CDI productivity by identifying and prioritizing cases with the highest propensity for documentation integrity improvement, i.e., reimbursement improvement through additional CC/MCC capture. In addition, there exists other software applications that “nudge” physicians through computer assisted documentation that prompts the physician to document “missed diagnoses” based upon available information in the chart. These offerings primarily focus upon diagnoses capture that impacts reimbursement or quality measures in some form or fashion. Coupling these software offerings with the CDI query process increases administrative burden of physicians by taking invaluable time away from direct patient care. Now that there is a documentation solution powered by AI-directed technology that automates clinical diagnoses with supporting documentation that populates into the chart where the physician can either accept, amend, or decline the suggested diagnoses in real time with minimal interruption of the physician, the question remains: How does this technology impact the CDI profession?

In participating with a client demo for this advanced documentation technology, that very question or concern surfaced. There was unequivocal pushback from the CDI director with reluctance to embrace a technology that not only enhances patient care but also produces notes that are complete and evidence-backed so they can be audited and easily read with no note bloat for payors and physicians to contend with. Note bloat significantly waters down the medical record and the patient story, oftentimes containing untimely and outdated information. My response to the CDI director pointed out the physician’s desire to provide high quality care, interest in spending less time documenting in the EHR with less administrative

burden, desire for less repetitive and reactionary queries by CDI and coding to contend with, and interest in easily assimilating all data available in the management of the patient to provide fully informed patient-centered coordinated care. The real sticking point obviously was the potential displacement of the CDI staffers. This is where I was able to interject a vision of CDI as mentors, guides, and facilitators of complete and accurate documentation to physicians.

Metamorphosing Into a Crucial Role

A practicing hospitalist colleague in conversation with my experience in the scenario as described above really summarized the situation nicely; the CDI profession must address the necessity to step up to the plate and “metamorphosize” into a new role, mirroring my assertion that CDI needs to evolve with the times. Reviewing records for CCs/MCCs can now be effectively captured and reported using the various physician documentation solutions available from different vendors. The software I had the privilege of seeing and evaluating provides testament to the need for the CDI profession to embrace transformational change in current CDI processes. These processes have reached their maximum shelf life, especially with the advent of AI-backed physician documentation improvement technology with increasing functionality and capabilities to drive real meaningful, measurable, sustainable improvement in physician documentation that is geared toward and embraced by physicians.

Several of my practicing hospitalist physician colleagues have raised an interesting valid point that every CDI professional should take to heart: If the CDI profession, both individually and collectively, does not commit to metamorphosing into the new role of collaborator and facilitator of good physician documentation that best communicates the patient care utilizing what I have coined the “8Ws” approach to documentation, the profession will experience a slow downward death and ultimate extinction. If you think about it logically and realistically, the CDI profession cannot improve the physician’s documentation; instead, only the physician

can improve his/her documentation. A deeply entrenched misnomer that currently exists is that documentation of a diagnosis by the physician through the query process constitutes actual clinical documentation improvement/ integrity. Typical volumes of payor clinical validation and medical necessity denials, as well as level of care and DRG downgrades, further gives credence and support to the fact that actual clinical documentation improvement has not materialized despite the efforts of clinical documentation improvement specialists. Current CDI processes were not designed nor intended to achieve any meaningful improvement in physician documentation; instead, they were designed and intended to capture additional reimbursement through capture of diagnoses such as sepsis and secondary diagnoses such as encephalopathy, which often are refuted by the payors. Advanced physician documentation utilizing artificial intelligence and natural language processing presents the opportunity for the CDI profession to advance and become an integral part of the revenue cycle through collaboration and team building, all a prerequisite for achieving notable meaningful clinical documentation integrity fundamental to ongoing hospital financial viability.

“The New CDI” Profession

What direction should the CDI profession be headed, and what steps should the CDI profession take to position themselves as facilitators, guides, mentors, and subject matter experts to physicians in their achievement of solid and complete documentation, treating the medical record as a communication tool versus reimbursement tool? The first step in this journey to role-based CDI versus today’s model of task-based querying farming CDI is to equip ourselves with the skill sets, core competencies, knowledgebase, and confidence in

standards by Medicare as constituents to capture centered, management record. This explains any, clinical been taking integrity, their consulting my next a forward-thinking career by best practice positioning currently documentation financial

With the saviors for times.

Glenn PCS, of Core-CDI.com. He matter an and promoting, achieving documentation. Core-cdi.com

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BEST PRACTICES IN

ENSURING ACCURACY AND COMPLIANCE RISK ADJUSTMENT AND HCC CODING

Healthcare is shifting from a fee-for-service model to a value-based care approach, focusing on quality and outcomes over volume. Risk adjustment plays a crucial role in ensuring fair reimbursement for health insurance plans, enabling them to maintain coverage and access to care for high-risk individuals with higher-thanaverage medical costs. Under this approach, providers must have a clear, concise, and comprehensive understanding of their patients’ health status and medical conditions. This is where Hierarchical Condition Category (HCC) coding comes in. The American Academy of Family Physicians states that the primary goal of HCC coding is to “communicate patient complexity and paint a picture of the whole patient.”

However, risk adjustment and HCC coding involves several challenges, including ensuring accurate documentation, coding updates, identifying and addressing coding gaps, and ensuring compliance with coding guidelines, all of which impact reimbursement and patient care.

This article discusses risk adjustment and HCC coding, highlighting its importance for reimbursement, patient care, and compliance. It also examines the key challenges in accurate coding and lists best practices to ensure precision under value-based care models.

Understanding Risk Adjustment and HCC Coding

Individuals with chronic conditions pose a higher risk to insurers. While those with mild health issues may have average medical costs, patients with multiple chronic conditions typically require ongoing care, leading to higher-than-average healthcare expenses. By taking the health status and complexity of patients into consideration, risk adjustment helps offset the higher financial costs of covering individuals with chronic or severe medical conditions, supporting the viability of health insurance plans under value-based care models.

Accurate HCC coding is essential for reimbursement, patient care, and compliance. It ensures fair compensation for providers by conveying the true complexity of a patient’s health, preventing underpayments due to incorrect coding. Proper HCC coding supports better patient care by capturing chronic conditions and enabling tailored treatment plans. It also drives regulatory compliance, reducing risks of penalties and audits while adhering with Medicare Advantage and risk adjustment model requirements.

Medicare Advantage plans and insurers use risk adjustment to predict future costs. HCC coding from one year helps estimate expenses for the next. For example, treating a patient with congestive heart failure costs more than caring for someone without chronic conditions, making accurate coding essential for budgeting healthcare spending.

HCC coding uses ICD-10 codes to identify a patient’s health conditions and determine their risk score, with each HCC linked to a specific ICD-10 code. Of the 74,000+ ICD-10 codes, less than 8,000 are mapped to the 115 HCC categories in the 2024 CMS-HCC Version 28 model. While most HCCs represent chronic conditions, some severe nonchronic conditions are also included. Chronic conditions persist over time and must be recaptured each calendar year for risk adjustment purposes.

HCC coding calculates a Risk Adjustment Factor (RAF) score based on documented HCC codes and along with factors like age, gender, and demographics.

Here are common HCC codes:

HCC 9: Lung and Other Severe Cancers

HCC 10: Lymphoma and Other Cancers

HCC 11: Colorectal, Bladder, and Other Cancers

HCC 12: Breast, Prostate, and Other Cancers and Tumors

HCC 17: Diabetes With Acute Complications

HCC 18: Diabetes With Chronic Complications

HCC 19: Diabetes Without Complications

HCC 22: Morbid Obesity

HCC 23: Other Significant Endocrine and Metabolic Disorders

HCC 27: End Stage Liver Disease

HCC 40: Rheumatoid Arthritis

HCC 59: Major Depressive, Bipolar, and Paranoid Disorders

HCC 77: Multiple Sclerosis

HCC 79: Seizure Disorders and Convulsions

HCC 85: Congestive Heart Failure

HCC 96: Specified Heart Arrhythmias

HCC 111: Chronic Obstructive Pulmonary Disease

HCC 134: Chronic Kidney Disease, Stage 5

These HCC codes enable healthcare providers and insurers to accurately identify and categorize patient conditions, ensuring appropriate care and resource allocation.

Here are some HCC coding examples:

Patient with Type 2 Diabetes with Diabetic Neuropathy

A patient diagnosed with Type 2 Diabetes Mellitus (ICD-10 code E11.9 - Type 2 diabetes mellitus without complications) and Diabetic Neuropathy (ICD-10 code E11.40 - Type 2 diabetes mellitus with diabetic neuropathy) would be assigned HCC 18 for diabetes with chronic complications.

Patient with Chronic Obstructive Pulmonary Disease (COPD)

A patient diagnosed with Chronic Obstructive Pulmonary Disease (COPD) (ICD-10 code J44.9Chronic obstructive pulmonary disease) would be assigned HCC 111 for chronic respiratory disease.

Patient with Congestive Heart Failure (CHF)

A patient diagnosed with Congestive Heart Failure (CHF) (ICD-10 code I50.9 - Congestive heart failure) would be assigned HCC 85 for congestive heart failure.

Major risk adjustment models include CMS-HCC, HHSHCC, and RxHCC. Developed by CMS, the CMS-HCC aims to determine risk-adjusted payments for Medicare Advantage (Part C) plans, based on expected healthcare costs of plan members. The HHS-HCC developed by the U.S. Department of Health and Human Services (HSS) focuses on determining payment transfers among participating plans under the Affordable Care Act (ACA), summing to zero within a risk pool. The RxHCC (Medicare Part D Risk Adjustment Model) developed by CMS predicts relative prescription drug spending to address risk adjustment specifically for the Medicare Part D (prescription drug) population.

Given the complexity of HCC coding, implementing best practices is essential for accuracy, compliance, better patient care, and proper reimbursement.

Best Practices for Accurate HCC Coding

Ensure Complete and Specific Documentation

To capture the most accurate HCC code, physicians must document all active chronic conditions including conditions that are relevant to the patient’s current care, i.e., the diagnoses being monitored, evaluated, assessed/ addressed, or treated – M.E.A.T. Even if the physician is not seeing a patient for a chronic condition, it should be documented. For example: a patient visits their physician for a routine check-up related to seasonal allergies, but has CKD Stage 3. Even though the visit is not specifically for CKD, the physician should document and code CKD (ICD-10: N18.3) to ensure accurate risk adjustment and proper reimbursement. All conditions in the patient’s medical record should be coded accurately and accompanied by supporting documentation about the status of each condition. Documentation linked to a non-specific diagnosis, as well as incomplete documentation, can negatively impact patient care and also reimbursement for the services rendered.

Identify Common Patient Conditions

All chronic conditions should be tracked. Practices should identify the most frequently encountered HCCs, determine the relevant codes, and ensure physicians prioritize documenting these conditions accurately. CMS requires that all qualifying conditions be documented at least once a year.

Implement Pre-Visit Preparation for HCC Patients

Physicians should review patient histories and existing chronic conditions before appointments, especially for complex HCC cases. This proactive approach ensures accurate documentation, comprehensive condition management, and proper risk adjustment coding, improving patient care and reimbursement accuracy.

Optimize EHR Systems for HCC Coding

Healthcare organizations should optimize their EMR systems by maintaining an accurate problem list, removing duplicate or inactive diagnoses, and utilizing a diagnosis preference list that includes HCC suffix codes and RAF values to enhance coding accuracy and risk adjustment.

Conduct Regular Coding Audits and Reviews

The AAFP and other organizations strongly advocate for regular coding audits (at least annually) to identify and correct coding errors, improve documentation, and ensure compliance with coding and billing guidelines. This is critical when it comes to HCC and risk adjustment coding.

Internal audits help identify potential risks such as undercoding, which can lead to lower reimbursements, or overcoding, which may trigger audits and compliance issues. External audits provide an additional layer of oversight, ensuring coding aligns with regulatory guidelines and payor requirements. Routinely reviewing documentation and coding practices minimize errors, improve risk adjustment accuracy, and enhance financial stability.

Stay Updated on Coding and Regulatory Changes

CMS regularly updates HCC models, ICD-10 codes, and risk adjustment guidelines, making it essential for healthcare organizations to stay informed. ICD-10 updates ensure coding reflects the latest medical knowledge and aligns with evolving clinical practices. These changes may introduce new HCC categories, adjust risk scores, or modify documentation requirements, all of which impact reimbursement and compliance.

Failing to stay current can result in coding errors, inaccurate risk scores, and financial losses, stressing the need for ongoing education. While coders must stay updated on coding changes, physicians should understand risk-based contracts, the role of HCC coding, and the importance of documenting chronic conditions. Engaging physicians in the coding process can help providers capture diagnoses correctly and drive better documentation practices. Practices must ensure proper use of patient management tools and reporting workflows to ensure seamless integration of risk adjustment practices.

Focus on Medical Record Review

Retrospective and concurrent reviews of medical records are essential for improving HCC coding accuracy and risk adjustment. Retrospective reviews involve analyzing past medical records to identify missed HCC codes, documentation gaps, or coding errors. Conducted in realtime, concurrent reviews involve assessing medical records typically during or shortly after a patient encounter. This proactive approach ensures that HCC diagnoses are properly documented, coded, and captured before claims submission, enhancing compliance and financial outcomes while supporting comprehensive patient care.

Common Pitfalls to Avoid in HCC Coding

With a clear understanding of best practices for HCC coding, it becomes easier to identify and avoid common pitfalls.

Here are some issues to watch out for:

Upcoding and downcoding risks: Upcoding or reporting a more severe diagnosis than the actual one or underreporting diagnoses can lead to compliance issues and financial penalties.

Missing chronic conditions that impact risk scores: Failing to document ongoing conditions lowers risk scores, affecting reimbursement and patient care.

Failing to capture diagnosis specificity: Lack of precise coding or using nonspecific or “unspecified” codes when a more detailed code is available can result in inaccurate risk adjustment and potential claim denials.

Precise documentation, regular coding audits, and provider education help ensure that all relevant diagnoses are captured correctly. Additionally, leveraging technology such as EHR systems and AI-assisted coding tools can improve efficiency and reduce errors.

The Rising Importance of Accurate HCC Coding in Value-Based Care

As value-based care expands and regulatory oversight tightens, accurate HCC coding is more crucial than ever. Proper coding not only supports effective patient management but also ensures fair reimbursement from payors. With the increasing complexity of HCC risk adjustment scoring, the demand for certified risk adjustment coders continues to grow to maintain accuracy and compliance. Outsourced medical coding services provide a strategic solution, leveraging experienced HCC specialists who stay updated with evolving guidelines and best practices. Partnering with an expert helps optimize reimbursements, reduce denials, and mitigate audit risks.

Natalie Tornese, CPC, is a Director of RCM, responsible for Practice and Revenue Cycle Management at MOS. She brings 25 years of healthcare management experience to the company. Natalie has worked in varied leadership roles with practices and specialties. Her primary focus is revenue cycle management with an emphasis on medical billing, coding, and insurance verification management. Natalie also holds a CPC certification by the American Academy of Professional Coders (AAPC). She has written numerous articles on all aspects of practice management, and presently manages a large team focused on medical billing, medical coding, verification, and authorization services for MOS (www.outsourcestrategies.com).

WALKING

THE TIGHTROPE

Delivering audit results to healthcare providers is rarely a straightforward task. When the data points to clear deficiencies—particularly those stemming directly from a physician’s documentation, coding choices, or clinical behavior—the conversation can quickly turn from professional review to defensive standoff. Healthcare auditors, coders, and compliance professionals are tasked with providing clear, unbiased feedback that ultimately serves the practice, protects compliance, and ensures appropriate payment. But what happens when those results are less than favorable, and the physician in question dismisses your findings or shifts blame elsewhere?

This article explores practical strategies for delivering audit results when the conversation gets uncomfortable— and how to transform these difficult moments into opportunities for education, collaboration, and improved outcomes.

The Nature of the Beast: Why Audit Results Stir Strong Emotions

Audits, particularly those that identify consistent errors, strike at the heart of a physician’s professional identity. Many physicians/APPs (advanced practice providers) view their clinical judgment, documentation style, and billing practices as extensions of their personal expertise. When those are called into question, the immediate reaction is often defense, denial, or even dismissal of the auditor’s competency.

Phrases similar to the following are all too common:

“That’s how I’ve always done it.”

“I’ve been coding this way for 20 years.”

“My notes are fine—the coders just don’t understand my specialty.”

Add to this the fact that healthcare compliance rules evolve constantly, and physicians/APPs often feel

they’re being judged against moving goalposts. In this environment, delivering poor audit results becomes more than a review; it becomes a delicate balancing act of diplomacy, education, and fact-based feedback.

The Art of the Delivery: It’s Not What You Say, It’s How You Say It

When audit results reveal physician-specific patterns of error, how you present the findings is critical.

Here’s a roadmap to maintaining professionalism while holding firm to the facts:

1 Lead with data, not opinion. Physicians/APPs respect evidence. Frame your results around the objective data from the audit, not subjective interpretation. Instead of simply stating, “Your documentation is incomplete,” specify, “In 14 of the 20 records reviewed, the medical decision making documentation lacked required components to support the level of service billed.” Concrete data is harder to argue with and shifts the conversation away from personal critique.

2 Acknowledge the complexity of compliance. Position yourself as a collaborative resource, not an adversary. Recognize the challenges that physicians face—balancing patient care with ever-evolving documentation rules—and position your audit as a necessary tool for protecting the practice. Try: “We know the rules have changed significantly in recent years, and we’re here to help everyone stay on the right side of compliance.”

3 Diffuse defensiveness with a team approach. When a physician/APP tries to deflect blame onto the coding team, billing staff, or even EHR templates, redirect the conversation to focus on shared responsibility. Remind them, “Documentation is a team effort, and it’s common for there to be gaps between clinical intent and how it translates into the record. Our goal is to help close those gaps together.”

When the Physician/APP Dismisses Your Expertise

Difficult physicians/APPs often dismiss audit results outright, or worse, attempt to undermine the auditor’s credibility.

In these situations:

Stay calm and professional. Don’t engage in emotional back-and-forth.

Anchor to regulations and guidance. Cite official sources like CMS, the OIG, or specialty-specific guidelines to reinforce your findings.

Offer a second opinion option. If the physician/APP insists you’re wrong, offer to bring in a third-party auditor or a medical director review. Objectivity is your greatest ally.

Document the encounter. If hostility escalates, maintain detailed notes about the conversation for compliance purposes. If the situation becomes overly aggressive or unproductive, it’s perfectly appropriate to end the meeting and reschedule once cooler heads prevail.

The Fine Line Between Blame and Accountability

One of the most challenging aspects of delivering audit results is when the data makes it clear that the physician/ APP is, in fact, the source of recurring issues, whether it’s upcoding, missing documentation, or medically unnecessary services. In these cases, your goal is to shift the focus from blame to improvement.

Consider the following phrase: “The audit identified a pattern that presents an opportunity for documentation improvement. Here’s how we can address it moving forward.” This allows you to maintain accuracy without alienating the physician.

If the physician/APP consistently refuses to accept responsibility, it may be necessary to escalate the issue to leadership—framing it not as an attack on the physician/ APP, but as a compliance risk for the entire organization.

Compliance Is a Culture, Not a Critique

FRAUD INDICATORS & RED FLAGS

PART 1 - WHEN AUDIT MANAGERS KNOWINGLY SKEW AUDIT RESULTS

Defining Terms

The Office of Inspector General (OIG) provides compliance guidance documents for healthcare provider use. There are also self-reporting mechanisms in place to report overpayments on the OIG website (Self-Disclosure) and Self-Referral Disclosure for voluntary self-reporting of overpayments on the Centers for Medicare and Medicaid Services (CMS) website. Detecting errors that result in potential overpayments is typically accomplished through efficient auditing and monitoring programs coordinated under the direction of the organization’s compliance officer or compliance department. But is the oversight of the audits manipulated to achieve particular performance goals? Could it result in the “cobra effect” (explained below)? Is anyone monitoring the integrity of the audit managers?

Tons of information can be found on the internet, in books and articles, etc. on fraud detection and prevention in healthcare. Typical publications and investigative reports illustrate involvement of providers, executives, and even lower-level employees.

But there is nowhere near the focus on mid-level managers, those who are the go-betweens of the C-suites and internal auditors and their immediate supervisors. Because the monetary variance with the executives/ owners is so different, they are left out.

In my experience, it appears that the mid-level fraud aspect is recognized primarily by two government entities,

one federal and one state, which will be referenced throughout this article.

The list of terms and definitions referenced throughout are the following:

• Cobra Effect: A situation where an attempted solution to a problem inadvertently makes the problem worse due to unintended consequences.

• Conspiracy: Britannica defines conspiracy as, “in common law, an agreement between two or more persons to commit an unlawful act or to accomplish a lawful end by unlawful means.” The Law Dictionary defines criminal conspiracy as “a combination or confederacy between two or more persons formed for the purpose of committing, by their joint efforts, some unlawful or criminal act, or some act which is innocent in itself, but becomes unlawful when done by the concerted action of the conspirators, or for the purpose of using criminal or unlawful means to the commission of an act not in itself unlawful.”

• Indicators and Red Flags: For the purpose of this article, the two terms are used synonymously: Signs of deception or suspicious aspects of behavior or misrepresentations that can lead to illegal payments or claims.

• Perverse Incentive(s): An incentive (reward or motivation) that unintentionally leads to negative or undesirable outcomes.

• Plausible Deniability: Although this can be found in dictionaries, there is no official, or even strictly

legal definition. An explanation is far more effective. The best by far is in the updated article, “Plausible Deniability Definition, Examples, and Laws,” in The Law Dictionary (July 17, 2022). It is not nearly as neat as one would expect, but the article displays how fraudsters who game the system apply this in their daily activities.

The article explains, “Plausible deniability is defined by the dictionary. But it’s not technically a legal term or defined in any legal documents. Which makes it a much looser term than it sounds. On top of that, plausible doesn’t mean trustworthy, possible, or even likely. Plausible means you could conclude that something might or might not be possible. But usually theoretically, superficially, or suspiciously. It doesn’t necessarily have to be a ‘reasonable’ conclusion, either. In its broadest sense, the term usually points to a lack of proof. After all, innocent until proven guilty is the backbone of our legal system. So, if there’s no proof, it’s plausible they could deny it.”

The definition continues to state, “Essentially, anything illegal or unethical that can be explained away under an innocent and probable guise—true or otherwise—falls under plausible deniability. Even if the plausibility of the denial is suspicious. However, in the ‘60s, the CIA took the term and expanded on what plausible deniability means to them. And the CIA’s version is the one that became popularized. To the CIA, it’s the act of withholding information from senior officials to protect their higherups in the event the information becomes public. Whether the information was actually withheld or not matters little in court if there’s no proof to the contrary.”

The Law Dictionary article goes further and indirectly shows us the dangers posed by managers who use it: “While it might seem like a minor tweak, the CIA’s definition puts blame on subordinates. This blame swap alleviates pressure on more senior officials. Which you may or may not frown upon. And I get that. Most people expect superiors to be held accountable for the actions of their subordinates. But if they have plausible deniability, the senior officials can’t be held accountable. This is true even if the actions clearly only benefit the superior who ‘wasn’t’ in the know. It also applies if an implication was made that spurred on illegal or unethical actions. An example would be a sinister comment in a suspicious tone followed by an equally suspicious exaggerated wink. That is, providing the superior can write it off as a misunderstanding. However,

in cases where someone genuinely didn’t know something was happening, they can’t reasonably be held accountable for the other person’s actions. Regardless of management practices and chains of command, if someone really doesn’t want you to know something, they’re really just not going to tell you. Famously, Ollie North (Lt. Col. Oliver L. North from the Iran-Contra scandal) called this situation ‘absolute deniability.’ Ollie’s argument was if you’re genuinely not aware of or did not do something, that’s not plausibility—it’s just not a thing.”

The article concludes that “This seemingly convenient loophole is meant to uphold the burden of proof. And— before you cry outrage—the burden of proof is for your benefit as well. So, it’s kind of important if you care about your rights. However, that’s not typically how we think of plausible deniability. And that’s certainly not how we’ve seen it pan out in the political or corporate arena. Realworld plausible deniability can (and does!) encompass things like thinly veiled threats, false advertisements, sexual harassment, stalking, discrimination against legally protected characteristics like race, age, gender, and sexual orientation, as well as a slew of other instances.”

Why Focus on Mid-Level Audit Managers?

The Data Speaks for Itself!

The Association of Certified Fraud Examiners (ACFE) conducts biannual surveys of its members, and one of the questions is what effect the perpetrator’s position has on fraud. ACFE has graciously given me permission to use their surveys and data for this publication.

Since the surveys began in 1996, questions on the survey focused on fraud committed by position. Three positions were given by respondents: (1) Executives/ Owners; (2) Employees; and (3) Managers.

A recurring trend emerged:

• Executives/owners account for the least number of cases but the most losses in money.

• Employees account for the greatest number of cases but the least amount of monetary losses.

• Managers account for fewer cases than employees but 250%-300% monetary losses.

The Data Speaks

Data gathered in 2018 was a sign of things to come. The ACFE survey found that most perpetrators were either employees (41.2%/median loss of $50,000) or managers (39.5%). But the median loss due to managers was $150,000—three times that caused by employee fraud.

In the ACFE’s 2020 survey, employees accounted for a median loss of $60,000 and managers for $150,000 or 2.5 times that of lower-level employees. In 2022, employees accounted for a median loss of $50,000, and managers again took a far larger proportion of median losses, totaling $125,000 or 2.5 times that of employees.

In the 2022 survey, the ACFE also stated “Frauds committed by higher-level perpetrators also typically take longer to detect… One of the challenges of dealing with fraud committed by high-level perpetrators is that these individuals often have the ability to evade or override controls that would otherwise detect fraud. Additionally, fraudsters in positions of authority might bully or intimidate employees below them, which can deter those employees from reporting or investigating suspected wrongdoing. Both of these factors might contribute to the longer duration of frauds committed by high-level employees.”

The ACFE completed its 2024 survey, with the following results:

• Employee fraud caused a median $60,000 loss; whereas

• Managers caused a massive $184,000 median loss.

In addition, the ACFE reported that, based on the surveys and monitoring over time, “Similarly, fraud cases perpetrated by individuals at higher levels of authority took longer to detect. The median duration of frauds perpetrated by employees was only 8 months…while frauds committed by mid-level managers had a median duration of 18 months….” (All figures and quotes used with permission of the Association of Certified Fraud Examiners).

Note: There are two reasons to retro back to 2018. One was to show the timespan and consistency of results. The second is to show that the data was consistent even during the pandemic and afterward. This opens an area gaining scrutiny: fraud committed in the remote workplace.

In the case of healthcare coding and documentation auditors, the primary directive is to ensure documentation is true and accurate, and that claims submitted reflect the work that was in fact accomplished, using specific and correct codes for encounters. When claims become involved, there will always be a financial element. However, performance and upward mobility within the organization becomes a component for dishonesty within mid-level audit management. Although most motivation to commit fraud is financial, coding and documentation audit manager performance is often based on coordinating information down for improved accuracy and upward to demonstrate the audit program is working.

A bigger issue is that red flags were unreported or intentionally misrepresented at a level beyond the auditors. This is where the mid-level leadership can be most dangerous as they form the “solid floor” to the corporate officers for upward transmission of information, and ostensibly a “communications ceiling” for the auditors and their supervisors, ensuring information goes down to the respective components.

In its current guidance, ”Fraud Detection Resources for Auditors,” there is a subsection titled, “Management Related Fraud Indicators.” This is interesting because of the mass availability of information singling out executives and employees but little recognizing mid-level involvement.

The DoD IG opens the subsection with a key statement: “Management sets the tone of an organization through its control environment. An organization’s control environment is the foundation of all other internal control components. An organization’s control environment includes integrity and ethical values, management philosophy, organizational structure, and self-governance. For a DoD contractor, active participation in a compliance program, integrity reporting, and the DoD Voluntary Disclosure Program are key parts of its control environment. The control environment provides both discipline and structure to the organization; therefore, auditors must consider management characteristics and influence over the control environment not only as fraud risk factors but also as fraud indicators along with the

Guidance From the Department of Defense Inspector General (DoD IG)

general and audit specific fraud indicators.”

Several of the sixteen indicators are reviewed below.

Fraud indicators listed by the DoD IG:

• Failure to display and communicate an appropriate attitude regarding the importance of internal control, including a lack of internal control policies and procedures; ethics program; codes of conduct; selfgovernance activities; and oversight of significant controls.

Be aware of an inappropriate or unreasonable argumentative attitude.

• Displaying through words or actions that senior management is subject to less stringent rules, regulations, or internal controls than other employees.

Managers have oversight and execution authority of internal controls. They have the ability to withhold and interpret the controls to their benefit at the cost or suppression of the auditors they are tasked to oversee. They may withhold compliance training, guidance, manuals, or conferences on the controls and processes reporting or proliferate “training” of their own to such an extent the auditors become separated from compliance knowledge or reporting routes.

At meetings, managers will not mention who they answer to, or how. They stay silent on their responsibilities for compliance.

• Hostile relationship between management and internal and/or external auditors. This would include domineering behavior toward the auditor, failure to provide information, and limiting access to employees of the organization

In some ways, this is a continuation of the indicator above but is an escalation as now the manager is forcing an adversarial relationship, hoping to bring it to a confrontational level, and the manager will feel justified in disciplining the auditor for insubordination or drive the auditor out of the organization completely.

• Failure to establish procedures to ensure compliance with laws and regulations and prevention of illegal acts.

One of two things, or both, will occur: Managers will make themselves the only contact to raise concerns or even ideas. The DoD IG, DHHS OIG, and government

contractors have complaint and whistleblower processes in place, but if they are not enforced, investigated, and confidentiality strictly adhered to, the auditor’s chances of a peaceful resolution are slim to none. Fraudulent managers know and exploit this; it is another tool in their scheme to silence a problematic voice in their environment.

• Indications that key personnel are not competent in the performance of their assigned responsibilities.

This is one of the more common non-financially driven fraud motives; an audit manager will not have the training, experience, or credentials of auditors they oversee. The manager cannot ask the right questions but feels their position is threatened by superior knowledge, which can result in closing lines and compliance avenues of communication.

When the manager is incompetent to fill the role, every red flag is fair game.

In addition, they justify their actions by telling themselves that only they deserve the position—not even necessarily that they earned it. In one of the cases below, two managers are conspiring against the audit team. The two managers involved did not even have certified auditing credentials, such as the Certified Healthcare Auditor (CHA) offered by AIHC.

In one case, the company had been in trouble with CMS several times. A current manager with no auditing credentials was emplaced to oversee random audits of Medicare claims. However, audits quickly discovered that the same manager was responsible for 84% of the continuing errors, and retrospective audits showed the same manager was responsible for much of the trouble uncovered by CMS auditors previously.

In this manager fraud case:

• The manager attempted to redirect the audits, but the audit supervisor did have auditing training, defended the auditor, and had already hammered out a solid audit plan and methodology, which the company’s compliance director and CMS approved, and she checked every item audited as a check-and-balance.

• Soon, the auditor and supervisor learned that the company had begun receiving serious inquiries from CMS about the managers’ lag time submitting the compliance audits, and they eventually “had to downsize” right when another sanction appeared looming. In total, nine people were downsized in the space of a week; in the middle of the “pack” or team were the auditor and supervisor.

This experience exposes two glaring problems with manager fraud:

• The manager was untrained, did not know how the audit was built, and demanded items with a certain ID (her own) be left out of all audits. Random means random; you cannot pick and choose which items you audit or report. It skews results and becomes a targeted audit—a type no recognized auditing organization allows when a statistically representative general sample is demanded.

• The manager did not understand what a universe or statistically significant sample was, or simple formulas for calculating them. The manager also did not understand the old axiom “numbers don’t lie.” The manager constantly attempted to reword, reinterpret, or omit facts of the audits when the audits had to be reported to the executives. During a meeting, the supervisor and auditor attempted to explain how CMS and the DHHS OIG used their statistical auditing system, called RAT-STATS. The outcome was no response and orders to continue with targeted audits.

Just as widespread, but carrying much higher risk, a manager can never be allowed to oversee and influence an audit where they have a direct stake in the audit outcome. No audit will be trusted. This goes back to the indicator about managers creating a hostile environment; they will have results altered by bullying, threatening, or confounding the auditor, or do it themselves and through use of plausible deniability draw suspicion on the auditor.

If there is conspiracy between the manager and the reporting executive or body, the damage goes from probable/possibly mitigated to unacceptably high risk. In this company, there was a conspiracy, but CMS uncovered it later. I do not know what happened to the two collaborators, but I do know that the compliance officer, who saved the company multiple times from CMS prosecution, was let go not long after the auditor and the supervisor.

Related fraud indicators listed by the DoD IG include:

• Undue interest and micromanagement.

We live in the information age, where information travels almost as fast as thought (or at least as fast as typing skills). Managers who demand inclusion on all emails, regardless of topic, are suspect, especially when a seemingly unrelated email is sent only to a coworker and a harsh email from the manager is the result. The danger signs are clear. The email never went to the manager; how did he or she intercept it? The email was unrelated to any sensible matter that the manager would be involved in. For example, if I asked a teammate for a copy of a pdf document because I couldn’t find it in my thousands of emails and e-files, why would I be criticized?

• A manager that claims disinterest or having no knowledge about a sensitive or high-profile issue in which you would expect management involvement.

An auditor informs the manager that the electronic system that pulls visits for audits has been only pulling specific dates or codes (remember, depending on the data, the system may be running its own targeted audit). The manager tells you offhandedly to “just do the audit.” Or you tell the manager that coders are assigning codes specifically prohibited (e.g., CMS-only codes) on commercial claims. The manager does not show appreciation and simply responds, “I’ll look into it if I have time.”

• Failure to effectively follow-up on recommendations resulting from external reviews or questions about financial results.

Failure to follow up on any serious concerns or recommendations from the audit team couples with the hostile work environment; rather than follow up professionally, the managers criticize the auditors.

Several of these management level indicators were further detailed in a guidance recently released by the State of New York Comptroller in his fraud guidance, “Red Flags for Fraud,” under “Management Red Flags.”

Thomas P. DiNapoli, State of New York

Comptroller Red Flags for Fraud

Mr. DiNapoli’s red flags for fraud include the following:

• Managers engage in frequent disputes with auditors. This can be read differently than the DoD IG’s indicator in that, here, the manager instigates and maintains irritating, false, or adversarial confrontations to bait the auditor into a situation which the manager can accuse the auditor of being insubordinate or keep the auditor confused or confounded about what the manager “wants.” This can flow into appeals if the manager oversees challenges to the auditor’s findings. The manager will overturn the auditor’s error and use such a vague or meaningless rationale that the auditor is forced to contact the manager and is sharply rebuked (again, the manager has avoided dealing with the auditor and supervisor). This tends to make the auditor continue contact, attempting to get a clear answer. Each time, the manager increases the inflammatory rhetoric or vague verbiage—and a cycle has begun. This is the entrance of a behavior/methodology addressed below: plausible deniability.

• Management decisions are dominated by an individual or small group.

Managers who are willing to retaliate without cause yet staunchly refuse to discuss their perceived “problems” with the auditor and supervisor and never forward concerns through the chain of command are dangerous; they keep vital information from the executives and compliance/fraud investigators above or laterally, while oppressing their subordinates and keeping them uninformed. In scenarios presented later, managers are in conspiracy; if concerns or perceived negative information is communicated, the managers meet with each other and no one else.

• Manager reluctance or refusal to provide information to auditors and their supervisors. This links directly to multiple red flags in several ways. As mentioned, appeal results will be intentionally confounding to the auditor, which puts the entire power of the outcome in the hands of the manager. The problem escalates when the manager is the first and highest reporting entity who receives audit reports. I have seen cases where information and/or data in an audit report was manipulated or deleted, and conspiring managers made claims that the auditor

was remiss, which went into their records for future “disciplinary actions.” In one example, even if the auditor keeps the reports in his/her e-files, after a short amount of time, the reports are deleted. The file is there in name, but can neither be opened nor retrieved. This can tie in to the hostile work environment; the manager chastises an auditor for “errors,” but either never provides specific, official guidance or provides “guidance” of the manager’s making (guidance was talked about at a meeting but never entered in an official manual).

• Inconsistent, vague, or implausible responses arising from inquiries or analytical procedures.

Mr. DiNapoli’s red flag above shows us that officials do recognize the use of plausible deniability. In the manager’s sphere of influence, this needs to be closely scrutinized by the executives and auditors—but especially compliance.

• There is a weak internal control environment; and

• Decentralization without adequate monitoring. These two red flags noted by Mr. DiNapoli are closely related. Their meaning may be the most important red flag there is as every other indicator or red flag can be built from it. The managers scrutinize the auditors, but who is scrutinizing the managers?

This gives fraudulent managers two key openings:

• First, when not monitored consistently, managers can manipulate almost anything—documents, conversation records, even information that goes up and/or down the leadership structure. Many boards and even civil courts will not allow mobile phone records because they can easily be manipulated.

• Second, they can target any perceived threat or opposition without question or investigation. This is where auditors who attempted to resolve problems locally become whistleblowers. They attempt to use the reporting systems in place, but because the managers failed to forward concerns to the reporting body above them, the concerns never go up. In addition, with decentralization, the higher authority often incorrectly trusts the manager because the “information” sent to them never covered complaints. Even worse, if the

higher authority was part of the hiring process, they have motivation to hide a potential hiring error.

Last in this group is a red flag usually associated with embezzlement, and often with employees, but it can happen in any setting, at any level where an individual wants absolute restricted control of information. This red flag is:

• Refusing vacations or promotions for fear of detection. Expanding an example from above, the manager who demands inclusion on all emails and intercepts irrelevant emails, as well as rebukes the auditor, goes on vacation, and the emails are still being intercepted whether relevant or not. The outcome is the same— criticism of the auditor for asking a question. Is the manager embezzling?

As auditors, we cannot know that. So how is this a red flag? Because the manager still has a chokehold on information flow. Let’s extend this: The manager is on vacation and your team is informed to contact her or his peer—another manager in the same position. You do as instructed, and either the manager on vacation answers your email, or the other manager answers your email but states that he or she will meet with the other “to discuss”—and no one else. Or worse, the manager on vacation calls you and the conversation becomes adversarial.

Another

Flag: The Use of Plausible Deniability

Some may think this is a term straight out of Hollywood, but it is still very real whether the fraud is primarily to protect a position or financially motivated. No matter which red flag or indicator we cover, plausible deniability is guaranteed.

In one case I’m familiar with, a manager contacted an auditor who had raised several concerns. The manager stated, “Your insubordination will not be tolerated. Any further complaints will result in your discipline, and we will make sure you get written up.” The supervisor learned about it and spoke to the manager. The manager replied with “I never said that. I simply stated that I needed more detail in the concerns your auditor was voicing.” It is believable (as far as it goes) but is a fabrication of what was said, actually saying nothing, and again is cutting off lines of communication.

In the example of the manager intercepting emails on vacation, when asked about it by the supervisor, states, “I was on PTO. I wasn’t even in the office.” The auditor has the response from the intercepted email, but the manager followed up with a phone call—it’s the auditor’s word against a higher level authority. Or, the manager was careful but knew full well the adversarial position regularly taken against the auditor. The response email will be vaguely worded or gray enough where “That’s not what I meant” could be viewed as a reasonable answer. A manager who uses plausible deniability regularly will have their own dictionary of denials at the ready.

The pandemic forced remote work on many organizations, and many continue to use this scenario as they are taking second looks at potential savings. For the cost of X number of computers for remote workers, and evaluating in-person or in-office time now from a part-time view, organizations are seeing potential cost savings in everything from previously assumed overhead such as electricity to space lease or rental and parking.

What would we term this relatively new motivation for fraud? I would say we call it decentralization. And because of this decentralization, the incentive to commit fraud increases—and involves every red flag and indicator we have discussed. In the office environment, an auditor could find someone, even a peer, to relate problems to. Remote work by its nature separates people. Or, as the managers see it, isolates them. Based on some data, isolation can cause employees at almost every level to struggle. But how will a manager use this, and remote work in general, to keep their position unquestioned?

The following case encompasses both incompetent managers and remote fraud, but there are more angles to the remote aspect, so I will put it here. Two managers had been hired; neither had certified auditing or compliance training, and the reason they were hired was never made clear. “New” processes were initiated but were not released to the audit team until significantly later with no feedback allowance—what CMS would term a “comment period.” Concerns were voiced but harshly rebuked, and auditors were singled out for disciplinary emails sent only to them, sometimes also to the supervisor. Meetings with them, the supervisor, and auditor were refused. When an auditor voiced concerns again, the managers waited six months, then complained to an external manager and demanded

Red

Manager Red Flags in the Remote Environment

without cause that the auditor be disciplined.

The two managers made it clear that no auditee was to receive ≥ 10 errors, and if the auditor stood their ground and the audit went to appeal, or the auditee complained to them directly, the auditor would be disciplined and errors in the report overturned in favor of the auditee. This causes a serious compliance problem; the auditee does not dictate the rules, or any aspect, of an audit. This is a red flag not found easily but applies universally; the auditee cannot, under any circumstances, be allowed to dictate the rules of the audit.

The overarching rule here is covered by every recognized auditing body I know of and, simply put, an audit is governed by rules, regulations, and laws—not the auditee. This is a point strongly made during my Certified Healthcare Auditor training. If an auditee is allowed to determine parameters of an audit, the audit becomes immediately suspect with the auditors vulnerable to fraud investigations against them. In this case, conspiracy extends beyond the two cooperating managers; they have now allied with the auditees, who will likely not “turn on them” as a quid pro quo.

Concerns had been voiced for several months that audit results were being skewed; the conspiring managers told the auditors that they had no choice. But a record was kept of a random sampling of several months’ audits in a specialty area, and of 100 total visits, 90 were of a type with such limited codes that it was nearly impossible to make mistakes. A third of those were postsurgical visits where not only the procedure codes were limited (to one only) but the diagnosis codes were also severely limited to one to two codes only. And this is regardless of the documentation. For practical purposes, it is almost impossible to arrive at 90 single-type visits with such mandatory restraints on code choice. Targeted audits have a place—after random audits have been completed, aberrations found, and concentration focused. But if an organization’s policy is random audits only, the manager has much to answer for.

This case fits in several categories and could be covered deeper in each, but now the managers’ game has an added

dimension mentioned previously. When the managers knowingly skew the results of the audits, and the audits are government, meaning they will be compiled and presented to Congress, the managers have added collusion to their list of illegal behaviors.

Conclusion

By their nature, auditors (and their oversight bodies) are adversarial. The auditors need to find errors to improve accuracy and reporting—and the auditees want to look the best because their throats are on the line when budget cuts come. Using plausible deniability, the managers claim, “We’re remote; we have no influence on the auditees, and we have records of reports filed. If anyone is acting maliciously, it is the auditors.” Because of the remote workspace, decentralization and a lack of strong internal controls, the managers have avoided a problematic scenario.

To read the rest of the story, see “Fraud Indicators and Red Flags: Part 2 - When Criminal Behavior Infiltrates Your Audit Program” at billing-coding.com in which you’ll learn how to detect what you don’t see, including withheld or altered information, as well as learn actions to mitigate risk and how to create a culture of compliance.

Carl J. Byron, CCS, CHA, CIFHA, CMDP, CPC, CRAS, ICDCTCM/PCS, OHCC, and CPT/03, USAR FA (retd.), is a coding and documentation auditor for the Defense Health Agency (DHA), a government agency that provides healthcare to the military. His background includes HCC auditing for CMS, coding and auditing for a large global healthcare network, and as a compliance educator and speaker for AIHC. He currently volunteers as a subject matter expert for AIHC, a non-profit licensing/certification partner with CMS.

www.aihc-assn.org

Understanding Internal Self-Referrals

Healthcare regulations outline legal risks related to internal self-referrals, making it important for both physicians and healthcare organizations to be informed about these issues. While internal referrals may seem like a natural part of integrated healthcare systems, they are heavily regulated under federal and state laws, particularly the Stark Law and the Anti-Kickback Statute (AKS). Violations of these laws can result in significant penalties, including fines, exclusion from federal healthcare programs, and even criminal liability.

Stark Law: A Strict Liability Framework

Stark Law, codified at 42 U.S.C. §1395nn, prohibits physicians from referring Medicare or Medicaid patients for certain designated health services (DHS) to an entity with which they (or an immediate family member) have a financial relationship, unless an exception applies. In addition, this is a strict liability statute, meaning that intent does not need to be proven for a violation to occur.

Key Elements of the Stark Law:

Designated Health Services (DHS): The Stark law applies to referrals for services including, but not limited to, clinical laboratory services, physical therapy, radiology, durable medical equipment and supplies, home health services, inpatient and outpatient hospital services, and more.

Financial Relationships: Any ownership interest, investment, or compensation arrangement between the referring physician and the DHS provider is scrutinized. Exceptions: There are numerous narrowly drawn exceptions that allow referrals under certain conditions.

These exceptions are constantly changing and evolving. Because these arrangements need to be carefully structured with appropriate agreements to satisfy an exception, a physician or provider should not, under any circumstances, attempt to address them without the assistance of qualified counsel.

Because the Stark Law is a strict liability statute, even unintentional violations can lead to severe penalties, including civil monetary penalties, repayment of claims, and exclusion from federal healthcare programs.

The Anti-Kickback Statute

The Anti-Kickback Statute (AKS), codified at 42 U.S.C. §1320a-7b, is broader than the Stark Law and applies to any arrangement where remuneration (anything of value) is offered, paid, solicited, or received to induce or reward referrals of services reimbursable by federal healthcare programs. Unlike the Stark Law, the AKS is a criminal statute and requires intent for a violation to occur; however, actual knowledge or specific intent is not required, meaning a person does not need to have actual knowledge of the law or specific intent to violate the AKS.

Key Elements of the AKS:

Prohibition of Kickbacks: The law prohibits offering or receiving anything of value in exchange for patient referrals.

Intent Requirement: As stated previously, a person does not need to have actual knowledge of the law or specific intent to violate the AKS.

Safe Harbors: There are numerous safe harbors that permit certain arrangements under the AKS if they meet specific conditions. Similar to the Stark Law exceptions, it is important to work with experienced healthcare counsel to ensure that an arrangement meets the Safe Harbor requirements.

Some common Safe Harbors are:

• Space and Equipment Rental Safe Harbor

• Bona Fide Employee Safe Harbor

• Personal Services Safe Harbor

Violations of the AKS carry significant penalties, including criminal fines, imprisonment, exclusion from Medicare and Medicaid, and civil monetary penalties. In addition, the Affordable Care Act amended the federal AKS so that a violation of the law automatically qualifies as a violation of the False Claims Act.

Best Practices for Compliance

To mitigate the risks associated with internal self-referrals, physicians and healthcare organizations should adopt robust compliance programs.

Key strategies include:

Conduct Regular Audits: Routine audits of financial relationships, referral patterns, and contracts can help identify potential compliance issues before they escalate.

Implement Training Programs: Physicians and administrative staff should receive training on Stark Law, AKS, and other relevant regulations.

Establish Clear Policies: Internal policies should clearly outline permissible and impermissible referral arrangements.

Seek Legal Counsel: Healthcare attorneys can help structure financial relationships and contracts to comply with Stark and AKS regulations.

Use Fair Market Value Assessments: Compensation and financial arrangements should be independently reviewed to ensure fair market value compliance.

Utilize Stark Law and AKS Exceptions/Safe Harbors: Arrangements should be structured to fit within the available exceptions and safe harbors.

Implement a Compliance Hotline: Allowing anonymous reporting of potential violations can help detect issues early and prevent liability.

Conclusion

Internal self-referrals pose significant legal risks under the Stark Law and Anti-Kickback Statute. While sending business to a friendly healthcare provider may seem like a natural practice, it can be extremely problematic in healthcare. By proactively implementing compliance strategies, educating staff, conducting thorough audits, and consulting legal experts, healthcare providers can reduce exposure to liability and ensure that their referral practices align with federal regulations. As regulatory scrutiny continues to increase, prioritizing compliance is essential for maintaining the integrity and financial health of healthcare organizations.

www.lilesparker.com

Telehealth and Advanced Practitioner Coding Considerations

With the increased utilization of both advanced practitioners (i.e., physician assistants [PAs] and nurse practitioners [NPs]) and telehealth, Health Insurance Portability and Accountability Act (HIPAA) covered entities need to stay abreast of the recent changes and the continued implementation of best practices.

On November 1, 2024, the Centers for Medicare and Medicaid (CMS) announced the Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule, which finalized changes to the Physician Fee Schedule (PFS). Telehealth was one of the items that received a lot of attention because of its adoption during COVID-19 and the changes that are occurring during 2025.

On the non-surgical PA front, there are also several updates regarding the American Medical Association (AMA) and CMS updates for telehealth services and coding requirements. Importantly, covered entities need to distinguish between what is permissible when treating and coding for a Medicare or Medicaid beneficiary and those individuals covered by a private payor.

A prudent practice is to update policies and procedures, as well as implement training and evaluate the current settings in electronic health records.

Analysis

Given the focus on telehealth, let’s begin with the November 1, 2024, CMS interpretation of the PFS and CMS’s “Telehealth FAQ Calendar Year 2025.” While the full PFS telehealth portion appears below, there are three key take-aways from both CMS published items: (1) Through March 31, 2025, Medicare beneficiaries can receive telehealth services in their home and do not need to be in a rural area or a medical facility; (2) Through March 31, 2025, any licensed practitioner who can independently bill Medicare may furnish telehealth services; and (3) “Incident to” codes are updated.

Importantly, the CMS website links to https://telehealth. hhs.gov/providers/telehealth-policy/telehealth-policyupdates, which indicates that “Medicare patients can receive telehealth services for non-behavioral/mental healthcare in the home through September 30, 2025.”

The November 1, 2024 excerpt follows:

Absent Congressional action, beginning January 1, 2025, the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 PHE will retake effect for most telehealth services. These include geographic and location restrictions on where the services are provided, and limitations on the scope of practitioners who can provide Medicare telehealth services. However, the final rule reflects CMS’s goal to preserve some important, but limited, flexibilities in our authority, and expand the scope of and access to telehealth services where appropriate.

For CY 2025, we are finalizing our proposal to add several services to the Medicare Telehealth Services List, including caregiver training services on a provisional basis and PrEP counseling and safety planning interventions on a permanent basis. We are finalizing to continue the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations for CY 2025.

We are finalizing that beginning January 1, 2025, an interactive telecommunications system may include two-way, real-time, audio-only communication technology for any Medicare telehealth service furnished to a beneficiary in their home, if the distant site physician or practitioner is technically capable of using an interactive telecommunications system, but the patient is not capable of, or does not consent to, the use of video technology.

We are finalizing that, through CY 2025, we will continue to permit distant site practitioners to use their currently enrolled practice locations instead of their home addresses when providing telehealth services from their home.

We are finalizing, for a certain subset of services that are required to be furnished under the direct supervision of a physician or other supervising

practitioner, to permanently adopt a definition of direct supervision that allows the supervising physician or practitioner to provide such supervision via a virtual presence through real-time audio and visual interactive telecommunications. We are specifically finalizing to make permanent that the supervising physician or practitioner may provide such virtual direct supervision (1) for services furnished incident to a physician or other practitioner’s professional service, when provided by auxiliary personnel employed by the billing physician or supervising practitioner and working under his or her direct supervision, and for which the underlying HCPCS code has been assigned a PC/TC indicator of ‘5’ and services described by CPT code 99211, and (2) for office or other outpatient visits for the evaluation and management of an established patient who may not require the presence of a physician or other qualified healthcare professional. For all other services furnished incident that require the direct supervision of the physician or other supervising practitioner, we are finalizing to continue to permit direct supervision be provided through real-time audio and visual interactive telecommunications technology only through December 31, 2025.

We are finalizing a policy to continue to allow teaching physicians to have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings, but only in clinical instances when the service is furnished virtually (for example, a three-way telehealth visit, with the patient, resident, and teaching physician in separate locations) through December 31, 2025. This virtual presence will continue to meet the requirement that the teaching physician be present for the key portion of the service.

Patient access to and the clinical provision of telehealth services by medical professionals are not the only areas of change. The American Medical Association (AMA) Current Procedural Terminology

(CPT) codes also changed. Telemedicine codes experienced an overhaul with 17 new codes being released, which include both audio-visual and audio-only services.

The breakdown of the new codes follows:

New CPT Codes: The 2025 CPT Manual includes 17 new codes for telemedicine visits, encompassing both audiovisual and audio-only services for new and established patients. For instance, codes 98000–98003 pertain to new patient visits, while codes 98008–98011 address established patient visits.

Virtual Check-Ins: CPT code 98016 has been introduced to replace the previous virtual check-in code G2012. This service is designed for established patients and must be patient-initiated, involving a 5-10 minute medical discussion unrelated to any evaluation and management (E/M) service in the prior seven days or leading to an E/M service within 24 hours.

CMS Policies: Through calendar year 2025, CMS will continue to permit distant-site practitioners to use their currently enrolled practice locations instead of their home addresses when providing services from their home. Additionally, teaching physicians are allowed to have a virtual presence for billing purposes when supervising residents in all teaching settings.

Where PAs are utilized, the following codes should be considered:

Modifier 25 Usage: For most non-surgical procedures, if a physician performs a significant and separately identifiable E/M service beyond the usual pre and postoperative work on the same date, it may be reported by appending modifier 25 to the E/M code. This ensures that the additional E/M service is recognized separately from the procedure performed.

Add-On Code G0559: CMS has introduced HCPCS code G0559 for post-operative care services provided by a practitioner other than the one who performed the

surgical procedure (or another practitioner group practice). This code reflects the time involved in post-op visits by practitioners the original surgery.

These updates strive to enhance the flexibility accuracy of coding for telehealth services situations. Ensuring documentation and coding going to be critical for avoiding downstream

For example, on August 19, 2024, the U.S. Department of Justice announced a False Claims Act settlement a practice for submitting claims for payment services were rendered by NPs or PAs not with Medicare and Medicaid and the physicians personal involvement in the supervision of practitioners (see United States and State rel. Nikki Patel v. Orange Medical Care, P.C., 8589 [PGG] [SDNY Aug. 13, 2024]).

In sum, providers and facilities are encouraged the new requirements, have a third party assess and coding practices, identify what should a medical record, and revise policies and procedures reflect these updates.

Conclusion

As it is said, “An ounce of prevention is worth of cure.” Distilling private payors’ permitted from Medicare permitted practices is going to avoiding potential False Claims Act liability return of overpayments. A proactive approach a third-party auditor explain the coding changes advise on language to include in the medical and implementing new policies and procedures training professionals, especially when advanced practitioners are involved, is crucial to avoiding adverse actions.

Rachel V. Rose, JD, MBA, advises clients transactions, government administrative and litigation involving healthcare, cybersecurity, corporate, and securities law, as well as Act and Dodd-Frank whistleblower cases. teaches bioethics at Baylor College of Medicine Houston. Rachel can be reached through www.rvrose.com

addressing workplaCe BUllying in a Manager’s gUide to a healthier offiCe CUltUre MediCal praCtiCes

Workplace bullying is a silent disruptor that can unravel the fabric of even the most dedicated medical practice. In an environment where precision, teamwork, and patient trust are paramount, the presence of repeated intimidation, exclusion, or disrespect can erode morale, compromise care, and drive away talented staff. For medical office managers, tackling this issue isn’t just about maintaining harmony; it’s about safeguarding the heart of the practice. Here’s a practical guide to recognizing, preventing, and addressing bullying in your medical office.

The Hidden Cost of Bullying in Medical Settings

Bullying in a medical practice isn’t always loud or obvious. It might look like a physician belittling a nurse’s input during a patient handoff, a receptionist consistently excluded from team updates, or a manager using sarcasm to undermine an employee’s efforts. These behaviors, often rooted in stress or unchecked power dynamics, create a ripple effect. Staff turnover spikes, burnout festers, and patient care suffers when teams can’t function cohesively. In a field where seconds matter, a toxic culture is a risk no practice can afford.

Here are four steps to address workplace bullying and promote a healthier culture in your practice:

Step 1

Define and Identify the Problem

The first task for managers is to name the beast. Bullying isn’t just a bad day; it’s a pattern of behavior marked by hostility, intent to harm, or a clear imbalance of power.

In a medical practice, bullying could be:

• A senior doctor dismissing a junior staff member’s concerns in front of patients

• Cliques forming among staff that isolate others from critical information

• Persistent nitpicking or public shaming disguised as “feedback”

To spot it, managers must listen. Watch for complaints about specific individuals, unexplained drops in team morale, or staff avoiding certain colleagues. Anonymous pulse surveys can also reveal what’s simmering beneath the surface without putting anyone on the spot

Step 2

Build a Bullying-Free Foundation

Prevention starts with clarity and commitment.

Here’s how to lay the groundwork:

Craft a policy. Write a concise, practice-specific policy that defines bullying (e.g., verbal attacks, sabotage, exclusion), applies to everyone from front desk to physicians, and outlines a confidential reporting process. Make it accessible—post it in break rooms and include it in onboarding.

Train the team. Hold a short, mandatory session to explain the policy and its purpose: protecting staff and patients alike. Use real-world examples (without naming names) to show what crosses the line, like mocking a colleague’s mistake versus offering constructive critique.

Lead by example. Managers set the tone. If you’re respectful, approachable, and quick to praise good work, others will follow. A culture of kindness starves bullying of oxygen.

Step 3

Act Swiftly and Fairly

When bullying surfaces, hesitation is the enemy.

Here’s a roadmap:

• Investigate quietly. If a report comes in—say, a nurse flags a doctor’s hostile outbursts—gather facts discreetly. Talk to the complainant, witnesses, and the accused separately. Keep it neutral; don’t assume guilt.

• Enforce consequences. If the behavior’s confirmed, act decisively. A verbal warning might suffice for a first offense, but repeat issues could mean mandatory training or even disciplinary action. Consistency matters—don’t let a star performer slide where others wouldn’t.

• Support the team. Check in with the affected staff. Offer a listening ear or access to an employee assistance program if stress lingers. Rebuild trust by showing that reports lead to change, not retaliation.

Step 4

Sustain the Change

A one-off fix won’t cut it. Make bullying prevention a living priority.

This is achieved through the following:

• Check in regularly. Add a quick “How’s the team vibe?” question to staff meetings or one-on-ones. Keep the door open for feedback.

• Celebrate collaboration. Highlight moments when the team shines together—whether it’s a smooth patient rush or a creative fix to a scheduling snag. Positive reinforcement drowns out negativity.

• Adapt as needed. If new stressors (like a staffing shortage) spark tension, tweak your approach. Maybe it’s more team huddles or a stress-relief perk like a coffee subscription.

For medical office managers, this isn’t just about rules; it’s about building a practice where people thrive. A bully-free workplace doesn’t just retain staff; it attracts the best, delivers better care, and earns patient loyalty. In an industry stretched thin, that’s a competitive edge worth fighting for. Start small, stay vigilant, and watch your practice grow stronger from the inside out.

Trained and professionally certified managers make a difference. Learn more about the CMM and HITCM-PP at https://my.pahcom.com/certifications.

The Bigger Picture

Upskilling in the AI Age Preparing Coders for a New Paradigm

Medical coding isn’t for the faint of heart. It involves accurately selecting from over 70,000 ICD-10 diagnosis codes and over 10,000 procedure codes while managing mounting backlogs and evolving guidelines, usually under time pressure. For years, this has forced a trade-off between speed and precision— contributing to denials that healthcare organizations spend $20 billion a year to fight.

Yet a transformation is coming: Artificial intelligence is taking on routine coding tasks, freeing medical coders to focus on complex analysis, guideline development, and provider education. These specialized roles, often previously deprioritized given the sheer volume of encounters to code, are reshaping the profession.

But what does this mean for coding professionals? This development goes further than just adopting new technology, it requires a fundamental reimagining of the coding role.

How Coding Changes With AI

The traditional model of medical coding faces daunting challenges. The industry is grappling with a 30% deficit of medical coders, with experienced professionals retiring faster than new ones joining the field. The results are predictable, and concerning: Staff shortages lead to rushed chart reviews that may result in details being overlooked. When combined with end-of-month deadlines and claim

submission pressures, this emphasis on speed to keep up underscores the urgent need for change.

Here’s where automation provides relief. By taking on the routine cases—the ones that often consume most of a coder’s day—AI creates space for coding professionals to focus on work that demands their expertise, diving deep into complex cases with the time and attention they deserve. The result? Better quality, clearer documentation, and, perhaps most importantly, more engaging work.

Succeeding in an Evolving Landscape

As medical coding evolves, three critical competencies are essential for future success: complex case management, guideline interpretation, and provider partnerships with shared documentation standards. Each skill builds upon foundational coding knowledge to form comprehensive expertise that sets coders up for career longevity.

Here are three critical competencies for future success:

Handling Complex Cases: While AI excels at routine encounters, human expertise proves invaluable for edge cases and specialized situations. Consider three common scenarios. Complicated surgical cases may have multiple procedures that overlap or require special modifiers. Encounters with conflicting or unclear documentation require professional 1

interpretation and potential provider queries to correct. And last, certain uncommon services falling outside standard coding patterns need deeper understanding of coding guidelines to ensure accurate capture.

To focus on these complex scenarios, coding professionals develop expertise across multiple specialties through enhanced cross-training programs. This broader knowledge base enables them to take on critical quality assurance roles, reviewing AI output to ensure consistency and compliance with coding guidelines.

Clarifying and Reviewing Coding Guidelines:

When coding teams have more time to invest in guideline review, they create a powerful ripple effect throughout the organization. Their systematic approach enables standardized protocols that prevent errors and denials.

Regular team meetings focus on automating routine interpretations while developing benchmarks for complex scenarios. This alignment allows both AI systems and human coders to apply guidelines consistently.

This proactive investment in guideline clarity yields measurable returns: reduced rework, fewer denied claims, and more consistent coding across the organization. For example, a major academic medical center in California revamped their coding operations by conducting a comprehensive review of E/M guidelines. This initiative yielded remarkable results: a 93.3% automation rate that eliminated coding backlogs and dramatically streamlined their entire coding process. Their success demonstrated how investing in thorough guideline analysis can drive both exceptional accuracy and breakthrough efficiency gains.

Provider Partnerships

and Shared Documentation

Standards: The final piece lies in provider

partnerships, centered on shared documentation standards that benefit both clinical and coding teams. Using insights from autonomously coded charts, providers and coders can align on terminology, phrasing, and other elements required for clean claim submission. This structured approach allows AI systems to code more cases accurately while ensuring providers receive appropriate credit for services performed.

In this way, organizations can leverage AI automation’s capacity for strategic work. When freed from routine coding tasks, coding professionals can dedicate time to analyzing documentation patterns across providers. One practical approach is reviewing coding en masse to identify improvement opportunities, then working with providers to address them. These structured reviews strengthen the bridge between coding and clinical practice, creating documentation that benefits the entire revenue cycle.

Embracing the Future of Medical Coding

These changes are already happening. Many leading health systems are building hybrid coding teams that combine human expertise with AI technology to maximize efficiency while maintaining quality.

As AI manages routine tasks, coding professionals excel in the work that truly demands their expertise—managing complex cases, interpreting evolving guidelines, and building strong provider partnerships. Working at the top of their license, these professionals translate their expertise into better healthcare: clearer documentation, fewer billing errors, and improved patient care.

Taylor Webster is Head of Coding Quality, and Tricia Lewis is Coding Quality Advisor at Fathom Health www.fathomhealth.com

DATA UNVEILED

THE IMPACT OF VBC AND AI ON PREVENTIVE CARE AND CHRONIC DISEASE MANAGEMENT

The conversation around chronic disease prevention remains critically important, both for ensuring patient and member health and achieving valuebased care (VBC) goals of reducing healthcare costs and improving care quality. The CDC reports in “Chronic Disease Prevalence in the U.S.” that more than 4 in 10 Americans (42%) have two or more chronic conditions, and 12% have at least five, so healthcare stakeholders— from payors and providers to self-funded employers and benefits administrators—are looking for effective ways to address the gaps in preventive care.

Recent analyses of commercially insured patients highlight these challenges, revealing stark deficiencies in preventive care for three of the most common chronic diseases. As reported by Business Wire, data reveals that more than half (53.5%) of women forgo their recommended screening mammograms despite breast cancer being the most common form of cancer. For heart disease, which remains the leading cause of death in the U.S., 31% of working Americans or family members have a cardiac disorder. Meanwhile, only 35% of COPD and asthma patients receive flu vaccines despite their heightened vulnerability to complications.

These findings highlight an urgent need for a more systematic preventive care approach that integrates advanced analytics and AI-driven predictive capabilities to close these gaps and improve patient outcomes

The Case for Preventive Care

Traditional fee-for-service (FFS) models reward volume and reactive care, which is counterintuitive to preventing disease onset and progression, and does not align incentives between patients, providers, and payors. Providers could potentially get paid more for latestage disease detection (which requires more intensive and costly care) or unmanaged chronic disease (which requires more frequent encounters with a healthcare system), leading to a perverse incentive system. While many providers do encourage patients to get preventive screenings and vaccinations, and proactively manage chronic diseases, the FFS pay structure doesn’t reward or support these activities. The end result of fee-for-service is an overburdened healthcare system with more sick patients, and increased financial strain on patients and payors.

By contrast, VBC aligns incentives across constituents throughout the healthcare ecosystem, and helps establish reimbursements aligned with patient outcomes. This benefits patients by focusing on actions that can improve their health over the long term, such as preventive screenings and vaccines. It benefits providers by aligning reimbursement to activities that improve patient health. And preventive care benefits payors as well as patients by minimizing unnecessary spending on emergency department visits, hospitalizations, and late-stage disease interventions.

For example, increasing the number of people who get their recommended mammogram screenings can improve outcomes for breast cancer patients by detecting tumors early when there are more options for effective treatment. Similarly, implementing targeted interventions for cardiac patients—identified early through AI-driven risk assessments—could help manage risk factors before they lead to serious events like heart attacks or strokes. By embedding these strategies into everyday healthcare workflows, providers can improve early detection and help patients manage chronic diseases before they escalate.

Patients, providers, and payors benefit from this shift, as improved health outcomes translate to lower long-term costs and better quality of life for individuals managing chronic conditions.

The Role of AI-Driven Analytics in Strengthening Preventive Care

AI is changing the way healthcare stakeholders approach preventive care by uncovering deeper insights into patient risk factors and improving care coordination.

Advanced predictive models powered by AI facilitate targeted interventions for some of the costliest chronic diseases, enabling large-scale risk reduction by delaying or avoiding disease onset, and slowing disease progression. However, to be effective, AI predictive models must have robust underlying analytics and a large pool of anonymized patient data from which to learn and improve

predictive capabilities over time. As AI capabilities increase, these tools are critical to assist providers and payors in optimizing outcomes, reducing costs, and addressing care gaps.

Today’s most advanced machine learning algorithms are capable of identifying individuals at high risk for chronic disease diagnosis in the coming year. These AI tools expand analytics capabilities beyond traditionally used rules-based logic, enabling analysis of a much wider range of metrics—including claims history, biometric screenings, and other health indicators—to detect potential cases that would otherwise have fallen below conventional diagnostic thresholds. Continuous collaboration between data scientists and clinical teams ensures the validation and improvement of these models.

AI can also optimize resource allocation by targeting preventive care efforts where they are needed most. For instance, health systems can use AI to direct resources toward populations with low screening rates, improving outreach and follow-up while reducing costs.

As the use of AI tools grows in healthcare, it’s also critical that companies developing these tools maintain the highest standards for data security and patient privacy, ensuring the responsible use of technology in advancing care. The stakes are high in healthcare, where users are dealing with patient lives. AI development must include robust testing to eliminate bias and error, and should never be intended as a replacement for the skill and knowledge of care providers. Instead, it should be a tool to augment providers’ capabilities to offer the right care, at the right time, in the right place.

Breaking Barriers to Preventive Care Adoption

Despite the clear benefits of preventive care, several challenges remain to get every patient the care they need. One major barrier is patient non-engagement, as many people delay or skip recommended screenings due to a lack of awareness, logistical hurdles (such as limited

access to convenient and ongoing care), or financial concerns.

Employers and insurers can help address these obstacles by offering incentives for preventive care adherence and expanding access to affordable and accessible care based on population needs. For example, if analytics reveals low flu vaccination rates in a specific geographic area, an organization could use that information to launch targeted mobile vaccine clinics in the area.

Health literacy is also an issue, as many patients remain unaware of the importance of early screenings or may not fully understand their own risk factors for chronic disease. Expanding outreach efforts and simplifying access to preventive care services—such as mobile-friendly scheduling, virtual consultations, and workplace health programs—can help bridge this gap.

Another significant challenge is the administrative burden on providers, who are stretched thin and may struggle to prioritize preventive care within their workflows. Fragmented patient data contributes to this burden, forcing providers and care teams to navigate multiple systems and formats to identify the patients with preventive care needs. Enterprise data management systems with advanced interoperability capabilities can help by unifying information from EHRs, claims data, and other sources, reducing silos and manual work. AI-driven insights further support providers by quickly sorting through all the available data to pinpoint the most pressing patient needs, streamlining decision-making, and improving care.

Aligning for Action: The Future of Preventive Care

A collaborative approach is essential to a value-based future where preventive care takes center stage. Employers, payors, and providers must work together to increase preventive measures, leveraging AI and predictive analytics to identify high-risk individuals. Health plans and employer wellness programs can encourage patient adherence to screenings and vaccinations with appropriate

incentives. At the same time, providers can use AI-driven risk stratification to tailor interventions to individual patient needs.

Ultimately, the success of preventive care strategies depends on a shift in mindset across the healthcare industry. Instead of waiting for patients to present with advanced disease, we must proactively identify at-risk populations and engage them in their healthcare journeys early. The integration of AI and VBC technology makes this possible.

As the healthcare industry navigates evolving value-based care models, embracing a more proactive, technologydriven approach to preventive care will be critical. AIdriven insights and VBC incentives provide a clear pathway for closing the gaps in early detection and chronic disease management, leading to a healthier population, lower costs, and a more sustainable healthcare system.

David L. Morris is EVP and Chief Commercial Officer at Cedar Gate Technologies. He has over 30 years of operational and executive leadership experience at blue-chip companies throughout the healthcare ecosystem. David drives client success across the value-based healthcare landscape by addressing the technology and service needs of the payor, provider, employer, pharma, and retail markets. He serves as Chief Commercial Officer with oversight of all commercial efforts, including market strategy, sales, and client success management.

Prior to joining Cedar Gate, David held key leadership roles as EVP and Chief Commercial Officer with Citra Health Solutions, Chief Revenue Officer with Eliza Corporation (acquired by HMS Holdings), Senior Vice President of Global Sales and Services with Bupa Health Dialog (acquired by Rite Aid), National Vice President of Healthcare for SAP America, IMS Health (acquired by IQVIA), Baxter and George Washington University (GWU) Medical Center.

David received his undergraduate degree from George Washington University’s School of Government and Business Administration and now resides in Boston, MA.

Awareness Healthcare Spotlight

May Is Mental Health Awareness Month

Mental Health Awareness Month, observed every May in the United States, has become a vital platform for raising awareness about the importance of mental well-being. Year after year, we witness a growing understanding and acceptance of mental health challenges, breaking down stigmas, and encouraging open conversations. However, awareness alone is not enough. For Mental Health Awareness Month 2025, the focus shifts: “Turn Awareness into Action.”

Developed by Mental Health America, this theme acknowledges the progress made in educating the public about mental healthcare but also emphasizes the crucial need to translate that knowledge into tangible change. It’s about moving beyond simply recognizing the existence of mental health issues and instead actively working toward creating a society that prioritizes mental wellbeing for all.

Why “Turn Awareness into Action”?

While awareness campaigns have been successful in reducing stigma, many individuals still face significant barriers to accessing mental healthcare.

These barriers include:

• Lack of Access: Limited availability of affordable mental health services, particularly in underserved communities.

• Systemic Inequalities: Disparities in mental healthcare access and outcomes based on race, ethnicity, socioeconomic status, and other factors.

• Continued Stigma: Despite progress, stigma still prevents people from seeking help.

• Insufficient Resources: Underfunding of mental health

services and research.

“Turn Awareness into Action” calls for a collective effort to address these challenges and create a more equitable and supportive mental health landscape.

What Actions Can We Take?

This year’s theme encourages individuals, communities, and organizations to take concrete steps to improve mental health. This is achieved by:

• Advocating for Policy Change: Support legislation that expands access to mental health services, increases funding for mental health research, and promotes mental health parity.

• Supporting Mental Health Organizations: Donate or volunteer with organizations that provide mental health services and offer support.

• Promoting Mental Health Education: Share accurate information about mental health with rich resources to your family, friends, and community.

• Creating Supportive Environments: Foster workplaces, schools, and communities that prioritize mental wellbeing and promote open communication.

• Practicing Self-Care: Prioritize your own mental health by engaging in activities that promote well-being, such as exercise, mindfulness, and spending time in nature.

• Being an Ally: Support individuals who are experiencing mental health challenges by listening without judgment and offering rich resources.

• Engaging in Community Initiatives: Participate in local events that promote mental health awareness and well-being.

The Impact of Action

By taking action, we can create a society where mental health is treated with the same importance as physical health. We can also ensure that everyone has access to affordable and quality mental healthcare. Taking action also allows us to eliminate the stigma behind having a mental health challenge. Individuals can instead feel

empowered to take action and seek help when they need it.

Mental Health Awareness Month is a call to action. It’s a reminder that we all have a role to play in creating a healthier and more supportive society for everyone. By turning awareness into action, we can build a future where mental well-being is a priority for all.

Research Facts

The National Alliance on Mental Illness reminds us that we are not alone. Mental health conditions are very common, but because of fear or shame, the stigma behind mental health challenges continues.

Here are some facts from NAMI:

• 1 in 5 U.S. adults experience mental illness each year.

• 1 in 20 U.S. adults experience serious mental illness each year.

• 1 in 6 U.S. youth aged 6-17 experience a mental health disorder each year.

• 50% of all lifetime mental illness begins by age 14, and 75% by age 24.

Continuing Advocacy

• Mental Health America (mhanational.org): Mental Health Month

• National Alliance on Mental Illness (nami.org): Mental Health Conditions

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist of SP Collaborative, LLC. Sonal has over 13 years of experience understanding the art of business medicine as a nationally recognized thoughtleader, speaker, author, creator, and consultant to elevate coding compliance education for the business of medicine.

ww.spcollaborative.net

how artifiCial intelligenCe will help or hinder the MediCal revenUe CyCle proCess

Artificial Intelligence (AI) is revolutionizing multiple industries, including healthcare. One of the most critical areas within healthcare that AI is influencing is the medical revenue cycle process. The medical revenue cycle involves all administrative and clinical functions that contribute to capturing, managing, and collecting patient service revenue. This includes patient registration, charge capture, claim submission, coding, payment posting, and accounts receivable management. AI’s role in automating and optimizing this process has the potential to either enhance efficiency and revenue or introduce new challenges that hinder financial operations.

How AI Helps the Medical Revenue Cycle Process

Enhancing Efficiency Through Automation: One of AI’s most significant advantages in the medical revenue cycle is its ability to automate repetitive and labor-intensive tasks. AI-powered tools can streamline processes such as patient registration, insurance verification, and billing. Automated systems reduce manual data entry errors, leading to fewer claim denials and faster reimbursement cycles.

Improving Medical Coding and Billing Accuracy: Medical coding errors are a major contributor to claim denials and lost revenue. AI-driven coding systems analyze patient records and medical notes to ensure proper code assignment, reducing human errors. These systems learn

from historical data to improve accuracy and compliance with ever-changing coding guidelines, such as ICD-10 and CPT codes.

Enhancing Claims Management and Denial Prevention: AI algorithms analyze historical claims data to identify patterns that lead to denials. By predicting and flagging potential errors before submission, AI helps healthcare providers correct mistakes early, reducing the number of rejected claims. AI-driven solutions also streamline appeals processes by suggesting corrective actions based on past successful appeals.

Accelerating Prior Authorizations: Prior authorizations are often a bottleneck in healthcare operations. AI-powered solutions automate the verification and approval process, reducing delays. Natural Language Processing (NLP) enables AI to extract necessary information from medical records and expedite approvals, ultimately improving patient access to care while reducing administrative burdens.

Optimizing Payment Posting and Reconciliation: AI can automate the reconciliation of payments from multiple sources, including insurance providers and patients. By identifying discrepancies and flagging underpayments, AI enhances revenue integrity and ensures that providers receive accurate reimbursements.

Enhancing Patient Engagement and Payment Collection: AI-driven chatbots and virtual assistants improve patient

interactions by providing automated reminders for upcoming appointments and outstanding balances. AI also helps predict patient payment behaviors, allowing providers to implement tailored payment plans and improve collections.

Fraud Detection and Compliance Support: AI-powered analytics identify fraudulent activities by detecting unusual billing patterns, duplicate claims, or discrepancies between clinical documentation and claims data. These systems help healthcare organizations maintain compliance with regulatory standards such as HIPAA and Medicare guidelines.

How AI Can Hinder the Medical Revenue Cycle Process

Implementation and Maintenance Costs: Despite AI’s benefits, the initial investment in AI-powered systems can be substantial. Smaller healthcare providers may struggle with the financial burden of acquiring and implementing AI solutions. Additionally, ongoing maintenance, upgrades, and training requirements can strain resources.

Integration Challenges With Existing Systems: Many healthcare organizations use legacy revenue cycle management (RCM) systems that may not be compatible with AI-driven solutions. Integrating AI with these systems can be complex, requiring significant IT investment and potential workflow disruptions.

Dependence on Data Quality and Availability: AI’s effectiveness is highly dependent on data quality. Incomplete, inaccurate, or inconsistent patient records can lead to incorrect AI-driven recommendations, resulting in claim denials, billing errors, or compliance risks.

Workforce Displacement and Resistance to Change: Automation of RCM processes may reduce the need for certain administrative roles, leading to workforce displacement. Additionally, employees accustomed to traditional methods may resist adopting AI-driven workflows, causing delays in implementation and reduced efficiency.

Security and Privacy Risks: AI-powered revenue cycle solutions rely on vast amounts of patient data, increasing the risk of cybersecurity breaches. Unauthorized access to sensitive patient financial and medical records can lead to compliance violations and reputational damage.

Ethical and Legal Considerations: AI systems must adhere to ethical and legal standards when processing patient data. Algorithmic bias and lack of transparency in decision-making processes can result in unintentional discrimination, regulatory scrutiny, and legal challenges.

Balancing AI’s Role in the Medical Revenue Cycle

To maximize AI’s benefits while mitigating its challenges, healthcare organizations should adopt a strategic approach:

Conduct a cost-benefit analysis. Assess the fiscal impact of AI implementation, including potential ROI and operational savings.

Prioritize data quality. Implement robust data governance practices to ensure accurate, standardized, and interoperable data.

Foster workforce training and adaptation. Educate employees on AI’s role in enhancing, rather than replacing, their work to ease transition challenges.

Ensure compliance and security measures. Invest in AI solutions that adhere to regulatory standards and prioritize cybersecurity protocols.

Choose scalable AI solutions. Select AI-powered tools that integrate with existing RCM systems to ensure smooth transitions without disrupting workflows.

In conclusion, AI has the potential to significantly enhance the medical revenue cycle process by improving efficiency, accuracy, and compliance. However, it also presents challenges, including high implementation costs, integration difficulties, and security risks. By carefully evaluating AI adoption and implementing best practices, healthcare organizations can harness AI’s benefits, while minimizing disruptions, ultimately improving financial performance and patient care.

Dave Jakielo is President and CEO of David D. Jakielo

Seminars and Consulting. Dave has over 30 years of hands-on management experience, speaking, consulting, and teaching business methods to managers, clerical staffs, business owners, and other industry professionals throughout North America, Europe, and Asia. Sign up for his FREE weekly Success Tips at www.Davespeaks.com. Dave can be reached via email Dave@Davespeaks.com; phone 412-921-0976.