Every disputed claim comes down to four questions.
Physician-led analysis of the points where a claim is actually contested: what the record showed, how it was coded, why it was denied, and who decides what the care was worth.
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Claim Dispute Overview
3 articlesThe shape of the payor and provider dispute itself: what is being contested, by whom, and with what tools.
Timing Is Not the Finding
A retrospective query is not a violation. The theories that survive rebuttal are built on how the query was constructed, on whether the addendum conforms to the recordkeeping principles, and on what the signer believed.
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The Year Billing Became a Battlefield
From simple billing errors to forensic warfare, how five trends are reshaping the way payors and providers fight over what care is worth.
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Inside the Algorithmic Arms Race
A hospital's AI flags the case for a high-DRG. Somewhere across town, a payor's AI is already running the same numbers in reverse. Welcome to the 2026 revenue cycle.
Read articleDiagnosis Accuracy
4 articlesWhether the clinical record supports the condition on the claim, and what happens to payment when the link is tested.
The Query That Never Went, and the One That Got Answered in Four Seconds
The 2026 query standard draws one line through both failures. Most query tools sit on the wrong side of it.
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The Seventh Condition
Sepsis Readmissions Enter The Medicare Penalty Program
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The Great "Social Complexity" De-Linking
CMS's own data says patients without housing cost more to treat. The FY 2027 Proposed Rule would stop paying hospitals as if they do.
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From Pay-and-Chase to Precision
Why the hospitals winning in 2026 are the ones auditing their own claims with the same forensic rigor a payor would, before the claim ever drops.
Read articleCoding
3 articlesDRG assignment, CDI practice, and the audit exposure created when the code moves ahead of the documentation.
Before Someone Else Finds It
A compliance officer's guide to Medicare Advantage risk adjustment: why it is in OIG's crosshairs, how the money moves, and five questions to ask your own program this week.
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The Four Second Signature
The vendor dashboard books the higher DRG as "new revenue." The EHR audit trail shows the chart was re-reviewed in four seconds. Only one of those numbers survives an audit.
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The Phantom Revenue
When aggressive hospital coding backfires, how CDI programs meant to capture revenue are quietly manufacturing audit exposure.
Read articleDenial Management
2 articlesWhat organizations do after the denial: which appeals get filed, which settings generate the most exposure, and what the data says about recovery.
The Appeals Nobody Files
Federal data has settled the question: denials are rarely appealed, and appeals usually win. If you lead a physician group, that gap is your money, and there is a playbook for closing it.
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The Longest Discharge
An inpatient psychiatric stay does not always end when treatment does. Inside behavioral health's three hardest claim settings, and the shared standards that can keep providers and payors on the same page.
Read articleFraud, Waste, and Abuse
2 articles
Nobody Is Watching The Visit
A compliance officer's guide to home health fraud: why it leads federal enforcement, how the schemes work, what the 2026 enrollment freeze means, and five questions to ask before a relator asks them for you
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Two Wound Care Problems, Not One
Most of what circulates about wound care fraud blends two different services, paid two different ways, with two different failure modes. An organization that reads about one and tightens controls on the other has aimed at the wrong exposure.
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Coming next
Analyses now in preparation, filed under the collection each one will join.
Two-Midnight Rule Compliance
Navigating CMS admission criteria and making inpatient status determinations that hold up on review.
Payor Litigation Trends
The arbitration landscape and the standards a medical-legal review has to meet to be defensible.
Peer-to-Peer Review Practices
How physician-to-physician review differs from a standard appeal, and the clinical findings that carry it.
CDI and Coding Optimization
How documentation practice drives DRG accuracy, CC and MCC capture, and sustainable performance.
Revenue Cycle Technology
Where 835 remittance automation, claim scrubbers, and AI tools fit inside a physician-led operation.
Denial Management Strategies
Reducing initial denial rates and building appeal workflows that reach a denial rate under 5 percent.
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