By Robin Sewell, CDIP, CCS, CIC, CPC, CCDS

How did the phrase “Clinical Validation” get coined when it comes to queries? As Clinical Documentation Integrity (CDI) professionals, we use that term essentially to “invalidate”, not “validate”, a clinical condition when there are insufficient clinical indicators to support it. …But do providers know CDI speak? Do they understand why they are receiving the query? Have we “mis-named” the query type, creating a misnomer? 

How often have you submitted a clinical validation query to rule out a diagnosis only to have the provider “confirm” or “validate” the diagnosis? 

To test out my theory, I “crowd-sourced” several Physician Advisors using a query that was the subject of a denial. The denial was for acute postoperative respiratory insufficiency.  The payer stated that the patient had normal postoperative weaning status post CABG, and as such, acute postoperative respiratory insufficiency was invalid.  

When I read the query, it was obvious to me that the query writer did not think the documented postop respiratory insufficiency was clinically valid, and it appeared their intent was to have it removed, aka “invalidated.”  

The Query In Question

Documentation includes the diagnosis of respiratory insufficiency on the pulmonary consult date xx/xx/25. 

Clinical Indicators: 

xx/10/25 Op note: Operation performed-CABG x2: LIMA to LAD, saphenous vein graft to diagonal, endoscopic harvest of left long saphenous vein… 

Post-Op diagnosis: Multi-vessel CAD 

XX/10/25 Pulmonary Consult: “… Acute respiratory insufficiency, postoperative-on vent postop, tolerating weaning per protocol…” 

XX/11/25 Pulmonary Consult: “… successfully extubated XX/10/25…” 

XX/11/25 Hospitalist Consult: “…Acute respiratory insufficiency, postoperative. Symptoms have resolved. Patient is currently on 3 L nasal cannula. He will be weaned off…” 

Based on the above, please further specify the patient’s respiratory status:

The intention of the query seemed clear to me: The patient was extubated on the same day as the procedure and was tolerating normal weaning.  I agreed with the payer that this was invalid; however, it was not so obvious to the physician.  

The Query Hypothesis

To test my hypothesis that physicians often misunderstand “clinical validation” (and to campaign for reforming the query process), I submitted the query to several physicians to get their opinion. It was an informal poll with these options, while encouraging feedback on their thought process:

1. The query writer wants me to select respiratory insufficiency (regardless of whether it is postop/pulmonary, etc.). 
2. Since the diagnosis is already documented, the query writer does not understand/read the clinical indicators very well.
3. The query writer suspects the diagnosis of acute pulmonary insufficiency is not clinically valid.
4. The query writer wants you to rule out acute or postop pulmonary insufficiency.  
5. Other

Providers who were not involved in CDI functions and who did not participate in clinical validation denials and appeals confirmed the hypothesis. Here were some of the comments by the physicians involved in the experiment:

• “Why would they think it’s not clinically valid? At the minimum the sedation is not allowing the patient to breath on their own.” 
• “I tried to take my knowledge out of the picture, and yes, if you sent this to a physician with minimal insight into coding and CDI, they absolutely would not know what the question is about.”  
• “I think I was asked so often in clinical life about these sorts of issues that maybe I never gave it much thought and just answered the best I could, assuming there was a good reason to be asked.” 
• “I would pick option 2 since the note on xx/10 states that dx. Also, it states that the patient had adequate oxygenation, with no mention of respiratory distress or hypoxia. Instead, it leans towards a quick wean off oxygen.” 
• “…for this case I think it’s straightforward. I don’t think you’d need an MD to validate it.”

These comments were very insightful. They revealed that many physicians do not understand clinical validation, and, as we already know, many do not understand coding guidelines. 

Where To Go From Here

So, what can be done to rectify this knowledge/communication gap? As we patiently await more guidance from AHIMA and ACDIS from an updated Query Practice Brief, can we at least call a spade a spade? What is it we really need from the provider? I vote we label these queries very plainly as “Rule Out Diagnosis.” Then, within the query itself, we clearly explain why.  

Dear Doctor: 

The documentation includes the diagnosis of respiratory insufficiency on the pulmonary consult date xx/xx/25, which has limited clinical evidence supporting it as a valid diagnosis.

Clinical Indicators: 

xx/10/25 Op note: Operation performed-CABG x2: LIMA to LAD, saphenous vein graft to diagonal, endoscopic harvest of left long saphenous vein… 

Post-Op diagnosis: Multi-vessel CAD 

XX/10/25 Pulmonary Consult: “… Acute respiratory insufficiency, postoperative-on vent postop, tolerating weaning per protocol…” 

XX/11/25 Pulmonary Consult: “… successfully extubated XX/10/25…” 

XX/11/25 Hospitalist Consult: “…Acute respiratory insufficiency, postoperative. Symptoms have resolved. Patient is currently on 3 L nasal cannula. He will be weaned off…” 

Based on the above, was the respiratory status normal postoperative weaning from vent, and thus acute respiratory postoperative insufficiency was ruled out: 

_ Yes- Normal postoperative weaning from vent (ruled out) 

_ No- Abnormal postop weaning from vent: Acute respiratory insufficiency, postoperative is clinically valid.

The Takeaway

This isn’t about changing compliance standards. It’s about improving communication clarity.

Because if the provider doesn’t understand the question, we shouldn’t be surprised when we get the wrong answer. 

Maybe it’s time to rethink the term “clinical validation query.” 

Because right now? 

It might be doing the exact opposite of what we intend. 

The post Query IQ: Clinical Validation Queries appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Pinellas Park, Fla. – April 8, 2026 

Brundage Group, a leading provider of physician-led, tech-enabled clinical compliance and revenue integrity solutions for U.S. hospitals and health systems, announced today that it has partnered with strategic health care investor, Water Street Healthcare Partners. The partnership comes as hospitals and health systems are facing mounting financial pressures, increasing medical necessity denials, and escalating regulatory and payer demands for patient care.

Through their partnership, Water Street and Brundage Group will enhance the company’s solutions, helping hospitals and health systems ensure patient care is thoroughly documented, clinically justified, and able to withstand payer and regulatory scrutiny. Brundage Group provides a full suite of clinical status integrity and denials management services, real-time analytics, and utilization management education delivered by top-tier physician advisors through a tech-enabled platform. Founded in 2007 by Timothy Brundage, M.D., Brundage Group has attracted a growing base of health systems and hospitals across the country.

“Our mission is to help hospitals and health systems remain viable to the communities they serve by ensuring clinical accuracy that supports fair reimbursement for patient care. Water Street shares our mission and brings deep industry expertise and resources to help us advance it. Together, we will invest in expanding our elite team of physicians and developing cutting-edge technology to empower more hospitals and health systems in delivering exceptional care to their patients and communities,” said Dr. Brundage, founder and CEO, Brundage Group.

About Water Street
Water Street Healthcare Partners is a strategic investor dedicated to building market-leading businesses in three critical health care sectors: medical products and diagnostics, pharmaceutical and life sciences, and health care services. The firm has completed more than 165 investments and acquisitions to build 48+ companies contributing to improved patient care, innovation, and a more efficient health care system. Working closely with leadership teams, Water Street contributes its industry experience and network of resources to support businesses’ growth objectives. Based in Chicago, Water Street’s team is a distinctive blend of health care executives, investment professionals, and functional specialists with decades of experience investing in and operating global health care businesses. For more information, visit waterstreet.com.

About Brundage Group
Brundage Group is a leading provider of physician-led, tech-enabled clinical and revenue integrity solutions for U.S. hospitals and health systems. Its team of top-tier Physician Advisors, proprietary analytics, and educational programs empower health care providers with ensuring inpatient care is thoroughly documented, clinically justified, and compliant with regulatory standards. Founded in 2007, Brundage Group is dedicated to enhancing clinical accuracy, regulatory compliance, and financial health for hospitals and health care systems nationwide, so they can focus on providing exceptional care to their patients and communities.

Media Contact:
Lacey Thompson
Senior Director of Marketing, Brundage Group
lthompson@brundagegroup.com

The post Brundage Group Partners with Water Street to Expand Clinical & Revenue Integrity Services for U.S. Hospitals & Health Systems appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

According to Becker’s Hospital Review, which referenced Kaufman Hall’s National Hospital Flash Report, hospitals ended 2025 with an adjusted operating margin of only 1.3%.

This number is well below the usual 3 to 4% margin hospitals need to:

• Maintain infrastructure and physical plants.
• Service debt obligations
• Fund baseline technology investments

With a 1.3% margin, hospitals lack financial stability that could lead to a reduction in services or closure.

Kaufman Hall characterizes the financial challenges facing hospitals in 2026 as a “new normal” defined by:

• Rising labor and supply costs
• Increasing bad debt associated with increasing uninsured and underinsured rates
• A deteriorating payer mix with increased payer friction
• A more complex and acute inpatient population
• Persistent margin compression

The Structural Deficit: Service Lines That Lose Money

The American Hospital Association’s (AHA) data show a deeper problem: core hospital services are losing money, regardless of payer.

These aren’t optional services. They are essential for community care. Hospitals can no longer offset these shortfalls with profits from other areas.

The Only Remaining Lever: Revenue Cycle Integrity

When core services lose money, and the payer mix worsens, hospitals have only one thing they can control.

Collect their earned revenue and fight hard to keep it. This shifts the revenue cycle from an administrative task viewed as a cost center to a margin-protection strategy. Payer friction is driving up the cost of healthcare. The AHA estimates that revenue cycle function account for as much as 40% of hospital costs. If current trends continue, the cost of collecting earned revenue could exceed the cost of delivering patient care.

Why Physician Advisors Are Now Mission-Critical

Hospitals are trying a variety of strategies, with the most common being the implementation of technology. However, the complexity of the inpatient revenue cycle is proving beyond the capabilities of many of these tools. Human intervention is still required. The bottom line is that hospitals need to expect more from their revenue cycle departments. In this environment, defensibility of clinical decision-making becomes the core asset.

Physician Advisors play a central role by:

• Educating admitting physicians about how to document to support medical necessity and accurate billing.
• Supporting status determinations (inpatient vs. observation) with clinical judgment.
• Conducting peer-to-peer reviews with payer medical directors to overturn adverse determinations.
• Leading appeals that convert denials into revenue recovery.

Successful status upgrades or appeals can yield thousands per case—critical when margins are 1.3%. This is a tangible, immediate benefit that accumulates over time.

Revenue Cycle as a Clinical Strategy

Hospitals that succeed in this environment share a common approach.

They treat the revenue cycle as:

• A clinical function, not purely administrative
• Real-time discipline and accountability, not retrospective cleanup
• A strategic capability, not a cost center

This includes:

• Embedding Physician Advisors into utilization management workflows
• Aligning utilization review, CDI, coding, and clinical documentation practices by breaking down silos
• Using data to identify denial patterns and problematic payer behaviors

The Bottom Line

The convergence of:

• Structurally negative service line margins
• Sub-2% operating performance
• Increasingly aggressive payer tactics

…creates a healthcare environment where: Revenue cycle performance is the margin.

Hospitals are fighting for financial stability, not just small improvements.

Hospitals that invest in physician advisors will protect their revenue. Those that don’t will see their margins shrink even faster.

Final Thought

The future of hospitals depends on decisive action. As financial pressures grow and essential service lines lose money, investing in efficient and effective physician-led revenue cycle strategies is not optional; it is vital. Hospitals that make revenue cycle integrity a top clinical and strategic priority will define the next era of healthcare. Defending every earned dollar is the difference between stability and decline. Organizations that act with urgency will lead; those that hesitate will fall behind, risking their mission and their communities. Now is the moment to lead. Protect your hospital’s future by investing in revenue cycle excellence.

The post Why Revenue Cycle Performance Is Now a Clinical Imperative appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Pinellas Park, Fla. – March 25, 2026 

Brundage Group, a physician-led leader in revenue cycle management (RCM) advisory and analytics, has again been recognized on Becker’s Hospital Review’s “385+ Revenue Cycle Management Companies to Know” list for 2026, marking the second consecutive year with this honor.

Becker’s publishes this list each year to highlight organizations nationwide that help healthcare providers manage financial challenges, improve operations, and strengthen revenue integrity. Companies are selected through a nomination process and recognized for making a real difference in the revenue cycle.

Furthermore, this recognition shows how Brundage Group stands out by combining physician expertise with advanced analytics to solve financial and operational challenges in healthcare.

“Being recognized by Becker’s for the second year in a row is a meaningful validation of the work our team does every day,” said Dr. Tim Brundage, Founder and CEO of Brundage Group. Hospitals are facing mounting pressure from reimbursement changes, regulatory complexity, and increasing denials. Our mission is to bring clinical credibility and actionable insights to help our partners protect revenue while maintaining the highest standards of patient care.”

Brundage Group’s solutions focus on the mid-revenue cycle, where clinical and financial performance come together. Moreover, the company offers Physician Advisor services, DRG validation, clinical documentation integrity, coding and audit support, and denial management strategies to help hospitals stay compliant, lower risk, and receive proper reimbursement for the care they provide.

Brundage Group takes a different approach from traditional RCM vendors by using a physician-led model that connects clinical teams with revenue cycle operations. As a result, this leads to more accurate documentation, better resource management, and stronger coding practices, which help reduce denials and improve outcomes.

Being included on Becker’s 2026 list confirms Brundage Group as a trusted partner for hospitals and health systems looking for lasting revenue cycle results in today’s complex healthcare environment.

About Brundage Group
Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions, including a full suite of physician advisory services, proprietary level of care analytics, and physician-led education to relay quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Learn more at brundagegroup.com.

Media Contact:
Lacey Thompson
Senior Director of Marketing, Brundage Group
lthompson@brundagegroup.com

The post Brundage Group Named Becker’s Top RCM Company 2026 appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

By Robin Sewell, CDIP, CCS, CIC, CPC, CCDS

In our last Query IQ article, we borrowed a line from The Princess Bride, when the character finally tells Inigo Montoya, “Stop saying that!” after hearing the same phrase repeatedly.

Apparently, we are continuing the Princess Bride theme this month. 

There is another famous line in the movie when Inigo tells Vizzini regarding his constant use of the term “Inconceivable!” 

“You keep using that word. I do not think it means what you think it means.” 

That’s often how CDI specialists and coders feel when a provider documents “sharp debridement.”

In the world of CDI and coding, “sharp” debridement does not necessarily mean that an “excisional” debridement was performed. 

Excisional Debridement 

Inpatient coding guidance has long been clear that describing a debridement as “sharp” or documenting the use of scissors, curettes, or other sharp instruments does not automatically qualify the procedure as “excisional” debridement. The documentation must include an “excisional” tissue removal  to code the root accurately as “excision.”  In the absence of such documentation, the procedure, if coded, is at high risk of denial and DRG downgrade. 

Over the years, CDI specialists and coders have become very good at querying providers to clarify the distinction between excisional and non-excisional debridement.

Identifying the Body Part and Layers Debrided 

However, even when the “excisional” question is resolved, another documentation detail can still create problems: The deepest anatomic layer debrided.

To be fair, documenting the depth of debridement has always been considered best practice. Under ICD-9-CM, however, coders often arrived at the appropriate procedure code through the Alphabetic Index and its sub-terms, where the available codes did not always require the same level of anatomic specificity.

ICD-10-PCS changed that. The coding construct requires coders to select the specific body system and body part directly from the PCS tables, making documentation of the deepest anatomic layer involved critical for accurate code assignment. 

The Payer Denial 

And this is exactly where a recent denial we reviewed came into play. 

In this case, the provider documented that the wound was debrided “down to healthy tissue.”  Well, that doesn’t translate to ICD-10-PCS coding. Therefore, a query for anatomic depth was submitted and answered as “down to fascia”. The payer denied the PCS code, reasoning that since the documentation did not explicitly state that the fascia itself was debrided, the procedure should not be coded at that level, and the DRG should be downgraded. 

Not so fast… 

In ICD-10-PCS, subcutaneous tissue and fascia are grouped under the same body system in the table below. Because these structures share the same body system construct, documentation supporting debridement to either level leads the coder to the same PCS table and body system, meaning the code assignment would not change even if debridement included only subcutaneous tissue. 

The coding is further supported by PCS guideline A10, which states: “And” when used in a code description, means “and/or” except when used to describe a combination of multiple body parts for which values exist for each body part.

Additionally, the phrase “down to” generally implies that the preceding tissue layers were debrided to reach that level. For example, to expose or reach the fascia, subcutaneous tissue would also be debrided, rendering the payer’s rationale for the denied questionable from both clinical and coding perspectives.

While this particular denial may have been a stretch, it highlights an important opportunity for documentation.

Querying for Debridement Procedures in ICD-10-PCS 

When querying providers regarding debridement procedures, it is helpful and compliant to include answer options that clearly identify the deepest anatomic layer debrided, such as: 

• Skin 
• Subcutaneous tissue 
• Fascia
• Muscle
• Bone

Using phrasing such as “down to and including” the specified anatomic layer can eliminate ambiguity and better align the documentation with the ICD-10-PCS coding structure. And of course, don’t forget the other words that still matter: “Excisional.” 

This same principle applies to procedures such as incision and drainage, where the deepest anatomic layer, i.e., the most specific body part, may be distinguished from an anatomic region, thus supplying the most specific code from the PCS coding table. 

Yes, providers may dislike these queries—and frankly, we don’t love sending them either. But when the coding system requires this level of specificity, CDI specialists and coders are simply translating the clinical documentation into the language required by ICD-10-PCS. 

So, the next time a procedure note reads “sharp debridement” and/or “down to” a particular layer, remember the immortal wisdom of The Princess Bride:  “You keep using that word. I do not think it means what you think it means.”

The post Query IQ: “You Keep Saying that Word…” appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

For those in revenue cycle management, clinical documentation integrity, utilization management, and compliance, conferences go beyond education by enabling professionals to connect, share challenges such as denials and reimbursement issues, and learn from peers facing similar issues.

Learning from Real-World Healthcare Revenue Cycle Challenges

At healthcare conferences, professionals discover how organizations address complex operational challenges.

Educational sessions often cover topics such as:

• Denial management strategies
• Clinical documentation improvement (CDI) best practices
• Physician Advisor support
• Utilization management optimization
• DRG Integrity

Exploring the Future of Healthcare Revenue Cycle Management

Healthcare conferences offer insight into industry trends. As technology, data analytics, and AI advance rapidly, organizations need to continually update their strategies.

Conference discussions often highlight emerging trends such as:

• AI-powered revenue cycle analytics
• Automation in utilization management
• Data-driven denial prevention strategies
• Physician-led revenue cycle advisory models

Understanding these trends helps healthcare organizations make informed decisions about modernizing operations and improving financial sustainability.

Continue the Conversation

At Brundage Group, we value the opportunity to meet with healthcare leaders, share insights, and learn directly from the professionals navigating today’s most complex revenue cycle challenges. Interested in engaging with our experts? Visit our conference and events page to schedule a meeting with us at an upcoming event.

The post Why Healthcare Conferences Matter for Revenue Cycle Leaders appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Pinellas Park, Fla. – March 4, 2026 

Brundage Group, a physician-led leader in revenue cycle management (RCM) consulting and Physician Advisor services, has been recognized by Healthcare Business Outlook as one of the Top 10 RCM Solution Providers in 2025. Additionally, the recognition highlights the firm’s continued leadership in delivering strategic, data-driven solutions that help hospitals and health systems optimize financial performance and revenue integrity.

This acknowledgement shows Brundage Group’s strength in physician advisory services, clinical documentation integrity, coding and auditing, mid-revenue-cycle optimization, denial management, and analytics. By working closely with healthcare organizations and using forward-thinking strategies, the company helps improve compliance, secure earned revenue for care already provided, and better connect clinical and financial operations.

“In today’s environment, healthcare organizations face mounting pressure from regulatory complexity, reimbursement changes, and increasing financial scrutiny,” said Tim Brundage, MD, Founder and CEO of Brundage Group. “Being named one of the Top 10 RCM Solution Providers for 2025 is a meaningful acknowledgment of our team’s commitment to helping our clients achieve sustainable revenue integrity.”

Brundage Group is physician-led, has strong clinical expertise, and is tech-enabled. Furthermore, this approach helps connect providers, coding professionals, and revenue cycle leaders. For instance, by offering hands-on support and leveraging advanced analytics, Brundage Group delivers practical solutions that drive real results in the mid-revenue cycle.

The Healthcare Business Outlook Top 10 RCM Solution Providers list honors organizations that demonstrate innovation, deliver measurable results, and have a proven track record of helping healthcare providers manage financial and operational challenges in a changing industry.

About Brundage Group
Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions, including a full suite of physician advisory services, proprietary level of care analytics, and physician-led education to relay quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Learn more at brundagegroup.com.

Media Contact:
Lacey Thompson
Senior Director of Marketing, Brundage Group
lthompson@brundagegroup.com

The post Brundage Group Recognized as a Top 10 RCM Provider appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

In today’s everchanging healthcare environment, internal hospital resources are insufficient to meet growing payer demands. Hospital leadership is realizing the importance of incorporating expert external Physician Advisors to help protect clinical decisions, remain compliant, and reduce payer-related financial risks. 

The Reality of Inpatient Practice Under Payer Oversight 

Hospitalists make important decisions quickly, often with limited information and changing patient needs. Meanwhile, payers review these cases later, using strict and inflexible criteria. 

Common inpatient payer challenges include: 

• Patient status disputes (inpatient vs. observation) 
• Medical necessity denials for inpatient admissions 
• Payment reductions from DRG downgrades or unauthorized days 
• Retrospective audits disconnected from bedside realities

These challenges put pressure on clinical judgment often leaving hospital physicians feeling like they must defend their treatment decisions as they address the needs of an increasingly older and complex healthcare population. 

Why Internal Resources Are Often Not Enough 

Many hospitals depend on internal utilization review or case management teams. While these teams are helpful, they often face limits such as: 

• Limited physician-level payer expertise 
• High patient volume and staffing constraints 
• Lack of authority in payer escalation pathways 
• Reactive rather than strategic denial management 

Without Physician Advisor-level expertise, hospital hospitals may fail to realize earned revenue for medical necessity decisions based on physician judgment.  

The Critical Role of Physician Advisors in Inpatient Care 

Expert Physician Advisors offer clinical credibility along with strong knowledge of utilization management, payer policies, and regulatory rules. Their job is not to second guess patient status orders, but to help explain clinical complexity in a way payers recognize as medically necessary. 

Expert Physician Advisors provide: 

• Real-time guidance to utilization review staff on inpatient admission decisions
• Credible defense of medical necessity decisions during concurrent payer reviews
• Documentation strategies aligned with inpatient medical necessity criteria
• Physician-to-physician advocacy during escalations and appeals
• Clinical bandwidth that allows hospital physicians to remain at the bedside

For hospitals, this guidance helps reduce uncertainty and protects their earned revenue from unfair payer challenges. 

Why External Physician Advisor Expertise Matters 

External Physician Advisors bring objectivity and a deep understanding of payer rules that internal teams may not have. They see payer practices across many hospitals, regions, and contracts. They often have relationships with payer physician advisors  

This external perspective allows Physician Advisors to: 

• Identify payer trends and emerging denial tactics
• Apply best practices across inpatient settings
• Provide consistent, defensible guidance independent of local pressure
• Strengthen hospital positioning during disputes and audits

This leads to fewer surprises and better support when payer issues come up. 

How Brundage Group Supports Physicians and Hospitalists 

Brundage Group provides expert Physician Advisor guidance tailored for hospital settings. Our Physician Advisors work with hospitalists, utilization management, and revenue cycle teams to support care decisions at every stage of payer review. 

Brundage Group’s Physician Advisor services include: 

• Inpatient admission and medical necessity guidance 
• Concurrent review and payer escalation support 
• Denial prevention and appeal strategy 
• Feedback to providers to strengthen their understanding of medical necessity 

With external Physician Advisor expertise, Brundage Group helps hospital physicians focus on patient care and makes sure patient status decisions are well supported and defended. 

Physician Advisor Support as Clinical Protection 

For hospital physicians, Physician Advisors act as an important layer of protection. They help maintain clinical independence, reduce administrative hassles, and ensure payer demands do not affect patient care. 

Hospitals that leverage expert external Physician Advisors experience: 

• Reduced inpatient denials and patient status downgrades 
• Improved alignment between clinical care and payer criteria 
• Less administrative burden on hospitalists 
• Greater financial and operational stability 

In today’s inpatient environment, payer oversight is not going away; in fact, it is increasing. Hospitalists and utilization management teams should not have to handle this complexity on their own. 

Expert external Physician Advisor guidance gives the experience, perspective, and support needed to handle payer scrutiny and keep clinical standards high.

The post Why Hospital Physicians Need Expert Physician Advisor Guidance  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Have you seen the scene in The Princess Bride where Inigo Montoya spends his entire life hunting the six-fingered man who killed his father? When he finally confronts him, he repeats, “Hello. My name is Inigo Montoya…” 

Eventually, the six-fingered man snaps back: “Stop saying that!”

This echoes the sentiment CDI and coding professionals sometimes feel when providers repeatedly document phrases such as “elevated troponin” or “demand ischemia” instead of the terms “myocardial injury” or “myocardial infarction” (MI). This clinical and documentation specificity is needed for accurate  coding appropriate reimbursement and accurate tracking of quality measures. 

Why “Elevated Troponin” and “Demand Ischemia” Are Problematic  

The Fourth Universal Definition of Myocardial Infarction clearly differentiates these conditions, which are also amenable to ICD-10 code assignment: 

• Non-ischemic Myocardial injury 
• Type 2 myocardial infarction (T2MI) 
• Type 1 myocardial infarction (AMI) 

When providers document using vague or outdated terminology, they unintentionally create ambiguity – remember urosepsis? Phrases like “elevated troponin” or “demand ischemia” often lead to mischaracterization of the patient’s condition, a lack of specificity and/or unnecessary documentation queries.  

Elevated troponin is an observation and not a diagnosis. Providers may use this term initially until a definitive diagnosis of myocardial injury or infarction is identified. Elevated troponin should never be listed as a final diagnosis.  

Demand ischemia represents the pathophysiologic mechanism for an elevated troponin and should not be used as a standalone diagnosis. If an elevated troponin is due to demand ischemia, the provider should then consider if there are signs/symptoms of ischemia. If yes, the diagnosis should be Type 2 MI. If no, myocardial injury would be most appropriate. Using the term “demand ischemia” alone may result in confusion and a lack of specificity requiring a potential query.  

Recent Documentation Example 

Revisiting the Clinical Criteria… 

According to the Fourth Universal Definition of Myocardial Infarction, Type 2 MI requires: 

1. A rise and/or fall of cardiac troponin with at least one value above the 99th percentile AND 

2. Evidence of myocardial oxygen supply-demand imbalance unrelated to coronary thrombosis, plus at least one of the following: 
   • Symptoms of acute myocardial ischemia
   • New ischemic ECG changes
   • Development of pathological Q waves
   • Imaging evidence of new loss of viable myocardium or new regional wall-motion abnormality consistent with ischemia

By contrast, myocardial injury is defined simply as: 

“Detection of an elevated cardiac troponin value above the 99th percentile upper reference limit.” 

In the above case, the patient had echocardiographic evidence of anteroseptal hypokinesis—a regional wall-motion abnormality consistent with ischemia. Even in the absence of chest pain or ECG changes, this finding supports a diagnosis of Type 2 MI in the setting of elevated troponin levels. However, the query provided options that led to an inappropriate diagnosis of demand ischemia. 

The Ineffective Query

According to the H&P, the patient was noted to have elevated troponin levels up to 1000 in the setting of sepsis. Additional documentation includes: “possible demand ischemia” in a progress note, “myocardial injury” in the discharge summary, and echocardiogram findings of “anteroseptal hypokinesis.” 

Can this clinical evidence and documentation be further clarified as:  

By adding options for “demand ischemia” and “myocardial injury,” the CDI or Coding Professional may  have unintentionally led the provider away from the most clinically accurate diagnosis. 

Query Tip 

Remember, the Query Practice Brief instructs us to add only clinically relevant options and to exclude all clinically irrelevant options. 

Coding Tip 

Type 2 MIs and Myocardial Injury should generally not be coded as principal diagnosis due to the instructional note indicating to “Code first, if applicable, the underlying cause” 

Here’s a practical reference to assist in query construction. 

The Takeaway

When you see “elevated troponin” or “demand ischemia,” pause. Review the record. Look for imaging, ECG changes, hemodynamic stressors, and clinical context. 

Educate your providers on key points:   

• “Elevated troponin” should never be a final diagnosis.  
• The term “demand ischemia” should not be a standalone diagnosis. Demand ischemia should be further specified as a definitive diagnosis of myocardial injury or type 2 myocardial infarction .  
• Use the 4^th Universal Definition of MI when applying the diagnosis of myocardial injury or type 2 MI  

Through education and effective queries, eventually, they will, “Stop documenting that!” 

The post Query IQ: “Stop Saying That!” appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) was on hiatus for over a year, but it is finally available again to short-term acute care (STACs) hospitals. Versions for other facility types are expected to be released in the coming months.  PEPPER is a comparative report that summarizes paid Medicare Fee-for-Service (FFS) claims by Medicare fiscal year (FY) quarter that may be at-risk for improper payment.  

Medicare Billing Compliance:

General Guidance 

Medicare has a couple of different Medicare FFS compliance tools. The Comprehensive Error Rate Testing (CERT), a program implemented in 1996 to estimate the national Medicare FFS improper payment rate, establishes target areas for all other Medicare FFS audit programs  (e.g., Medicare contractors such as Medicare Administrative Contractors and Recovery auditors). It is the only program in which Medicare contractors may randomly select claims for audit. Audited STAC claims are classified as a hospital outpatient (Part B), Part A (excluding hospital inpatient prospective payment system – IPPS), and Part A (hospital IPPS). CERT findings are published annually.  

To determine the improper payment rate for Medicare Part A in 2025, 18,041 claims were sampled, and 8,750 were reviewed, resulting in an improper payment rate of 3.1% (Table A1). Currently, Medicare Part A has the lowest improper payment rate of all claim types audited by CERT. Medical necessity errors accounted for the largest share of improper Part A payments at $2.9 billion (Table A5). As expected, the improper payment rate is higher for shorter inpatient admissions stays (zero to one day) with a rate of 17.8% of claims billed to Medicare Part A. This is somewhat surprising since the Medicare Two-Midnight Rule has been in use since 2013 with limited modifications since that time.  

Medical necessity denials can have a greater impact on revenue than coding errors. When an inpatient claim is denied payment under Medicare Part A, how quickly the organization corrects the patient’s status determines the extent of the revenue leakage. If patient status is corrected quickly, the hospital may be able to bill observation services in addition to separately billable Medicare Part B services, if an order is placed and at least eight hours of observation care is provided.  

Unfortunately, due to limited utilization review (UR) staffing, antiquated UR workflows, lack of Physician Advisor support and other factors, medical necessity errors usually are not caught until the patient has been discharged, preventing the hospital from the ability to bill observation services.  

Medicare Billing Compliance:

Hospital Specific Guidance 

Where CERT provides general information for all hospitals, PEPPER provides hospital-specific information. The format and structure of PEPPER allow a hospital to easily identify specific MS-DRGs that may be vulnerable to improper payment due to medical necessity errors.   

PEPPER Methodology: 

PEPPER is designed to highlight specific target areas that are vulnerable to medical necessity or coding errors that can contribute to improper Medicare payments.  In this blog, the focus is on medical necessity target areas, but there is overlap between these areas as some are the result of both medical necessity and coding errors. These include: 

• Percutaneous cardiovascular (CV) procedures 
• Knee Replacement
• Syncope
• Digestive System Diagnoses
• Medical Back
• Spinal Fusion
• 3-Day Skilled Nursing Facility (SNF)
• 2-Day Medical MS-DRGs
• 2-Day Surgical MS-DRGs
• 1-Day Medical MS-DRGs
• 1-Day Surgical MS-DRGs

What sets PEPPER apart from other Medicare audit tools is that hospitals are compared against their peers at the state, jurisdiction, and national level. This comparison allows Medicare to identify hospitals that are outliers, defined as those in the top or bottom 20 percentiles within each comparison group. Medicare recommends that hospitals are outliers confirm that their revenue cycle practices are compliant with Medicare billing requirements.  

Compare target reports (Table 2) can be extremely helpful for hospital leadership to understand the relationship between medical necessity denials and hospital revenue. This table includes a column for the sum of payments. In the sample ST-PEPPER 2025 Q3 report available on the PEPPER website, the dummy data reveals the hospital as a high outlier for the target areas of Percutaneous CV procedures and medical back.  

Specifically, the hospital had 23 Medicare Part A claims that generated $349,280 in payments. Because this is a quarterly report when multiplied by four, this provides an estimate of annual dollars at risk within this one target area: $1,397,120. It is unlikely that all these claims will be denied. Still, even if a fraction of them could have a detrimental impact on hospital finances, especially if the hospital has a low or negative operating margin.  

Conclusion 

Far too often, hospital leadership views UR as a cost center and is reluctant to invest in resources to optimize accurate Medicare billing, including the use of external vendors. In a healthcare environment where payer denials are increasing year-over-year, it is not only the payments at risk, but the cost associated with appealing denials that must be considered. American Hospital Association Report found, “administrative costs now account for more than 40% of total expenses hospital incur in delivering care to patients.” Furthermore, they argue, “hospital staff must expend valuable time and resources to overturn inappropriate denials, adding unnecessary cost and burden to the health system.”    

The post Examining Medical Necessity Compliance in Medicare Part A  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

On January 27, 2026, CMS announced that 2027 Medicare Advantage (MA) reimbursement rates will remain nearly unchanged from 2026, marking a significant development for the healthcare revenue cycle. This decision is so consequential that U. S. News and World Reports estimate U.S. health insurer shares would lose about $80 billing in market value.  

Healthcare finance operates as a zero-sum game. When reimbursement stagnates, payers protect margins by any means necessary, which may include increasing denials. With minimal base rate growth and ongoing pressure to control medical cost inflation, insurers will increasingly use denials and utilization management tactics to maintain profitability.

Payers Have Already Gone “All In” on the Risk Model Adjustment  

Over the past decade, managed care plans, especially those with a significant Medicare Advantage (MA) presence, have positioned themselves to benefit from MA’s risk-adjusted payment model.

Payers have invested in: 

• Proprietary technology platforms that aggregate, analyze, and stratify risk data; AI-enabled algorithms to optimize risk adjustment; and automated denials workflows. 
• Ownership or affiliation with physician practices.

This strategy increased revenue share. However, with CMS proposing a 0.09% net increase for 2027, well below expectations, the approach now faces a critical turning point. 

Flat Reimbursement and HCC Scale Back Doesn’t Reduce Cost — It Reduces Margin 

Flat reimbursement does not reduce costs. Inflation in labor, pharmaceuticals, chronic care, and outpatient utilization persists. At the same time, changes to Hierarchical Condition Category (HCC) scoring and risk adjustment are expected to further reduce revenue needed to maintain margins. 

With limited growth in capital income, payers will likely respond with stricter claim adjudication. The healthcare industry is also likely to see more health plans implement reimbursement policies that reduce hospital payments like Aetna’s decision to reduce inpatient hospital payments using MCG criteria. Expect more medical-necessity denials, aggressive plan edits, tighter pre-authorization requirements, and increased pre- and/or retrospective reviews are expected to increase. Hospitals should prepare for rising denials as payers shift focus from growth to margin protection. 

What This Means for Hospitals 

• Longer revenue cycle timelines, 
• A higher volume of complex and contested denials,
• The need to investment in technology and staffing to minimize revenue leakage and appeal denials.

Hospitals, especially those with large Medicare and Medicare Advantage populations, face two main concerns: 

1. Expense inflation continues to outpace revenue growth. 
2. Reimbursements remain flat, widening the cost-to-care gap.

Strengthening revenue integrity through efficiency and expertise is now essential. External Physician Advisor experts can help hospitals anticipate payer tactics. 

Why External Physician Advisor Support Matters 

As Medicare Advantage pressure increases, hospitals need more than reactive denial management. They need proactive clinical and revenue protection. 

A Physician Advisor team that understands both patient care and payers’ tactics can help hospitals: 

• Spot denial trends early, so problems are addressed before they impact revenue. 
• Strengthen documentation to clearly support medical necessity, and appropriate DRG assignments.
• Reduce preventable denials by aligning revenue cycle decisions with payer rules from the start. 
• Support physicians in real time with guidance on status, utilization, and documentation.
• Protect earned revenue by improving claim defensibility and appeal success. 
• Reduce the administrative burden placed on bedside providers associated with defending admission orders. 

Instead of constantly playing defense, hospitals gain a proactive Physician Advisor partner at Brundage Group who helps protect revenue, strengthen clinical decision-making, and helps hospitals play offensive to stay ahead as payer scrutiny intensifies. 

The post Why Flat MA Reimbursement = More Denials and Financial Strain  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Hospital margins may appear stable but are expected to be fragile in 2026. Vizient’s New Margin Math shows this stability masks pressures, including rising costs, more complex patients, workforce shortages, payer dynamics, and policy challenges. These factors threaten sustainability without proactive intervention. 

Given today’s rising complexity and costs, settling for “good enough” documentation now translates directly into financial risk and missed strategic opportunities. 

Documentation is no longer routine – it’s a primary driver of operational and financial resilience.  

Why Documentation Matters More Than Ever 

Vizient’s analysis highlights multiple forces reshaping hospital economics in 2026: 

• Higher acuity and utilization: Demographic shifts, especially an aging population, are increasing utilization and clinical complexity, which raises both inpatient and outpatient care needs. 
• Shifting reimbursement mix: Reliance on Medicare, Medicare Advantage (MA), and commercial payer negotiations, along with policy changes like evolving site-neutral payments and expiring subsidies, has increased reimbursement volatility. 
• Rising non-labor costs and workforce constraints: Labor costs remain high, supply and specialty drug costs outpace reimbursement growth, and workforce shortages strain capacity. 
• AI and technology can reduce waste, but only if workflows are redesigned rather than added to existing processes. 

Lapses in accurately capturing severity, risk, and interventions do more than just threaten coding and revenue; they undermine a hospital’s overall strategy for surviving industry headwinds. 

Accurate coding starts with documentation that captures patient acuity and clinical complexity, including not only the principal diagnosis but also all relevant comorbidities, complications, and interventions that affect resource use and reimbursement. 

With rising acuity and reimbursement pressures, incomplete documentation risks revenue losses tied to care intensity. Precision coding supports revenue integrity. 

Documentation must be prospective, not retrospective. It must anticipate payer’s expectations and denial triggers before submitting a claim. Real-time clinical documentation integrity, integrated with care teams, ensures clarity at the point of care.

This means switching from reactive to proactive workflows. CDI specialists should engage during care, not after discharge. 

• Implement triggers and alerts to identify ambiguous, missing, or insufficient documentation as cases progress. 
• Provide educational opportunities that enable clinical teams to use coding language effectively without compromising clinical judgment. 

Post-discharge reviews, algorithms, and AI are no match for complete, accurate, and consistent documentation during the patient’s admission. While payers can enhance their audit strategies and tools, they cannot erase or modify our real-time documentation once the record is solidified. 

Vizient’s analysis shows that technology, especially AI-assisted tools, reduces administrative burden and waste when integrated with redesigned workflows for clinicians and revenue teams. 

This means: 

• Add intelligent automation to routine documentation, like drafting clinical summaries or structured data, to reduce burden and improve consistency. 
• Integrate real-time feedback among EHRs, CDI, and coding systems to find gaps early, not later. 
• Align documentation tools with data goals to ensure analytics reflect clinical realities and support insights. 

Without a tech foundation, documentation is siloed, inconsistent, and error prone.  

Are Your Current Documentation Efforts Future-Ready? 

The trends Vizient highlights, fragile margins, rising acuity, and shifting payer pressures, are realities shaping executive priorities across health systems. 

Documentation must move beyond compliance and serve as a lever for financial and operational success, shaping organizational adaptability in a changing environment. 

As a Physician Advisor, my charge is clear: documentation must amplify the true clinical story, comprehensively and precisely, to protect financial sustainability in 2026 and beyond. 

• Precision in coding ensures accurate acuity capture and protects reimbursement. 
• Complete, accurate, real-time documentation is the strongest defense against evolving payer audits, serving as an “insurance policy” that prevents denials and strengthens revenue integrity.
• Effective tech integrations improve efficiency and reduces documentation errors and waste.

Review your organization’s current documentation practices now. Identify gaps, set measurable improvement goals, and develop a targeted action plan to align documentation strategy with anticipated financial and clinical challenges. Assign dedicated leadership to oversee progress and routinely measure results to ensure sustainable margin resilience in today’s evolving healthcare landscape. 

The post “Good Enough” Documentation Is No Longer Good Enough  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

However, today’s environment tells a different story. Between physician workforce shortages, increasing payer complexity, and the growing oversight required for tech-enabled workflows, fully insourced Physician Advisor programs are becoming increasingly difficult for staff, sustain, and scale. 

By 2036, the nation will face a physician shortage of 86,000. Demand for Physician Advisor expertise is climbing 6–9% annually, while the available physician workforce declines.

Hospitals recognize the reality that Brundage Group has long understood. External Physician Advisor support is no longer optional; it is essential. 

Return on investment (ROI) is driven by expanded specialty expertise, coverage continuity, and organizational-scale insight—not increased per-physician workload. 

Why the Market Is Moving to External Models 

Hospitals are not abandoning insourcing entirely—but they are redefining it.  

Three market realities drive this shift: 

1. Physician Advisor Demand is outpacing supply. 
Escalating payer friction, growth of Medicare Advantage population, and increasing payer scrutiny are driving demand for qualified Physician Advisors faster than the workforce is expanding, resulting in a sustained supply-demand imbalance. 

2. Internal models cannot absorb volatility. 
A single resignation or high-denial month can destabilize hospital revenue cycle operations. External programs provide insulation, efficiency, and continuity. 

3. AI is adding oversight responsibilities, not removing them. 
AI accelerates case generation—but human clinical oversight remains essential. External Physician Advisor teams are already structured to manage the combined human + tech-enabled (AI) workload. 

How Brundage Group Fits into the Future Landscape 

Brundage Group is purpose-built for the realities hospitals face today. We provide: 

National-scale Physician Advisor coverage. 
Hospitals gain immediate access to a fully staffed, highly trained clinical team without the burden of hiring and ongoing training. 

Turnover does not disrupt hospital revenue cycle operations. PTO does not reduce coverage. Surges do not overwhelm staff. 

Integrated technology that accelerates reviews. 
Automated triage, AI-enabled insights, and streamlined workflows give hospitals capabilities that would take years to build in-house. 

A full spectrum of revenue cycle management resources. 
Status determinations, DRG optimization, denial prevention, peer-to-peer support, and appeals—handled by a cohesive team. 

Meaningful, measurable financial impact. 
Partners see stronger documentation, fewer denials, higher overturn rates, and enhanced revenue protection. 

The Bottom Line 

The question facing hospitals today is no longer “Should we insource?” but “Can we sustain it?” As demand rises, complexity intensifies, and staffing constraints grow tighter, internal Physician Advisor programs face increasing operational and financial risk. 

External Physician Advisor support provides the stability, expertise, and scalability hospitals need to protect revenue.

Brundage Group is ready to support organizations through this transition with proven solutions, national experience, and measurable outcomes. We partner directly with your UM teams, strengthen internal relationships, and integrate seamlessly into your revenue cycle operations to function as an extension of your team. 

The post Why External Physician Advisor Support Is Essential  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

A recent conversation with a hospital IT leader underscored a shift many organizations are experiencing. The question was not whether inpatient optimization has value. The question was more strategic:

“Why should my team invest time and resources into implementing this now?”

Today’s IT leaders are balancing cybersecurity threats, EHR optimization, data governance, infrastructure modernization, and a growing portfolio of enterprise initiatives. Every project must demonstrate measurable value and alignment to organizational priorities.

Patient Status Accuracy Has Become a Real-Time Enterprise Risk

Hospitals are under increasing pressure to make accurate patient status determinations in real time, not retrospectively. Payer scrutiny is intensifying. Denial activity is rising. Margins remain constrained. The window to support medical necessity and defensible documentation is measured in hours, not days.

Even highly effective Utilization Review (UR) teams face structural limitations:

• Volumes fluctuate daily
• Staffing varies by shift and service line
• Nights, weekends, and holidays create unavoidable coverage gaps
• Manual workflows depend heavily on individual availability and experience

The outcome is not a reflection of effort or competence. It reflects the system design. Without consistent, real-time identification, opportunities are missed, and risk accumulates.

Financial and Operational Impact

When leaders evaluate inpatient statuses through a global lens, the implications become clear:

• A typical missed inpatient conversion represents approximately $6,500* in lost net revenue.
  • *The 6,500 figure represents the average payment differential between Observation and Inpatient status, based on client claims data for 2025.
• Missing just one patient per day can equate to approximately $2.4M annually.
  • **$6,500 x 365 = $2,372,500
• Late conversions materially increase denial exposure and downstream administrative burden.
• Manual processes create inconsistency even within strong teams.

This is not simply a revenue cycle challenge. It is an organizational risk management issue.

How Tech-Enabled Automation Changes the Equation

At Brundage Group, we view automation not as “another system,” but as an operational standard. Our tech-enabled approach to UM is designed to create consistency, visibility, and reliability across patient status workflows.

Certus Radar, Brundage Group’s proprietary automation and utilization management solution, is purpose-built to continuously analyze clinical and operational data to identify inpatient-appropriate cases early in the stay. Rather than relying on manual chart review, Certus Radar functions as an always-on layer of intelligence across the organization.

Certus Radar consistently surfaces high-value cases in real time, allowing organizations to gain a level of operational reliability that manual processes cannot achieve alone. Opportunities are identified regardless of staffing levels, shift coverage, or timing.

A well-designed, tech-enabled approach enables:

• Consistent identification of high-impact cases
• Earlier intervention, while documentation remains clinically defensible
• Reduced dependency on perfect staffing conditions
• Operational coverage that effectively extends 365 days per year

This is not about replacing clinical expertise. It is about ensuring clinical expertise is applied to the right cases at the right time.

What We Observe After Implementation Is Often the Most Revealing

A common trend occurs after organizations deploy Certus Radar alongside external Physician Advisor support.

Across organizations, total inpatient upgrades often increase, even when overall conversion rates eventually normalize. The conclusion is straightforward: the opportunity existed all along. It was not surfaced consistently.

Technology does not just create opportunities. It provides visibility into what was previously hidden by workflow constraints and variability.

Benefits Extend Beyond Securing Earned Revenue

The value is not limited to financial performance.

By automating routine case identification, UR and clinical teams gain capacity to focus on:

• Strategic collaboration with physicians
• Stronger documentation integrity
• Improved discharge planning and throughput
• Reduced manual chart-mining and administrative burden

The downstream effect is improved operational performance, more substantial clinical alignment, and a more maintainable workload for highly skilled teams.

Strategic Implication for IT and Executive Leadership

This is not about asking IT to do more. It is about enabling IT to play a central role in protecting global performance.

Tech-enabled status determinations, powered by Certus Radar, support executive priorities:

• Securing earned revenue
• Reducing compliance and denial risk
• Strengthening clinical and operational alignment
• Creating consistency where variability currently introduces exposure

Brundage Group is physician-led, tech-enabled, and results-driven. We combine clinical expertise, advanced analytics, and proprietary technology to help hospitals strengthen performance without placing additional strain on already limited resources.

As organizations evaluate priorities, inpatient optimization is increasingly less a discretionary enhancement and more a foundational capability for sustainable performance.

The post Why Projects Targeting Accurate Patient Determinations should be an Executive IT Priority appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Nationwide revenue cycle solutions provider helps hospitals navigate the complexities of clinical revenue cycle management.  

Tampa, Fla. – January 12, 2026

Brundage Group, a leading physician-led healthcare consulting and revenue cycle solutions provider, remains committed to delivering high-quality service and strategic support to hospitals and healthcare organizations. As part of a market clarity initiative, Brundage Workforce Solutions (BWS) will undergo a brand transformation becoming VelarityHCS in January 2026, establishing a distinct identity separate from Brundage Group. Brundage Group and VelarityHCS will maintain a strategic alliance in the mid revenue cycle.

“This evolution allows Brundage Group to maintain its mission and focus on supporting hospitals’ operational and financial performance without change,” said Tim Brundage, MD, CEO of Brundage Group. “Our leadership, services, and client relationships remain the same, ensuring continuity and consistency for our organizations.”

What This Means for Brundage Group Clients:

• No changes to services, teams, or client relationships
• Continued collaboration with the trusted professionals you know
• More apparent distinction between Brundage Group and BWS to reduce market confusion
• No disruption to operations, delivery, or communication
• A strategic approach that positions Brundage Group for continued growth and client impact

Brundage Group remains fully focused on helping hospitals strengthen documentation, optimize revenue, and sustain long-term viability in the communities they serve.

For Questions or More Information:

Brundage Group

Lacey Thompson, Senior Director of Marketing

lthompson@brundagegroup.com

618.521.2188

Brundage Group appreciates the continued trust of its clients and partners and looks forward to further advancing its mission of supporting hospitals and healthcare organizations nationwide.

The post Brundage Group Clarifies Market Focus as Brundage Workforce Solutions (BWS) Rebrands appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Intelligent automation, purpose-built for Utilization Management (UM), Clinical Documentation Integrity (CDI), and revenue cycle operations, are no longer optional. It is essential. Certus Radar integrates advanced automation with physician-led advisory and analytics to deliver a high-performance, modernized clinical revenue cycle.

Below are three reasons your organization needs automation in 2026 and why Certus Radar provides the advantage hospitals need.

1. Automation Fills Persistent Staffing Gaps and Boosts Efficiency

Labor shortages continue across case management, UM, and CDI. Turnover disrupts productivity and increases variability in clinical revenue cycle processes.

Certus Radar addresses these issues by:

• Identifying and executing high-volume, rules-based clinical reviews instantly
• Prioritizing cases that require Physician Advisor intervention
• Reducing manual administrative tasks so staff can focus on higher-value work

Because Certus Radar is backed by Brundage Group’s expert Physician Advisors, hospitals achieve efficiency, increased accuracy, and stable operations—even with leaner teams.

2. Automation Reduces Denials and Strengthens Compliance Before Claims Go Out the Door

Denial complexity continues to accelerate. Manual processes introduce inconsistencies that increase both financial and compliance risk.

Certus Radar reduces this exposure by:

• Standardizing clinical review workflows
• Flagging documentation gaps in real time
• Applying evidence-based criteria with reliable consistency
• Ensuring every case receives the appropriate level of review

Paired with Brundage Group’s analytics and physician-led reviews, Certus Radar helps hospitals reduce avoidable denials, protect compliance, and reinforce revenue integrity.

3. Automation Delivers Real-Time Visibility to Empower Confident Leadership Decisions

Leaders need real-time visibility into clinical, operational, and financial performance—not retrospective reporting.

Certus Radar delivers this clarity through integrated analytics that highlight:

• Case mix and inpatient ratio
• Denial patterns and underlying drivers
• Length-of-stay implications
• Documentation accuracy and query opportunities
• Sources of preventable revenue leakage

When automation, analytics, and advisory expertise operate in unison, hospitals gain the operational clarity and financial strength required for long-term resilience.

Why Certus Radar

Brundage Group gives hospitals the confidence to overcome revenue and compliance challenges through physician-led advisory, data-driven analytics, and intelligent automation. Certus Radar is the culmination of those capabilities: an automation platform built by experts who understand the clinical, regulatory, and financial nuances behind every decision.

In 2026, hospitals that succeed will be those that eliminate friction, enhance accuracy, and empower their teams with technology that accelerates, not replaces, clinical decision support

The post Three Reasons Hospitals Need Automation in 2026 appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

1. Strategic Partnership Is Now the Standard 

In 2026, hospitals are relying on Physician Advisors to drive clarity across Utilization Management (UM), documentation integrity, denials management, and payer relationships. Brundage Group’s Physician Advisors leverage deep clinical expertise and proven operational insights to navigate the complex criteria, support documentation accuracy, and ensure medical necessity is clearly and consistently documented, advancing both compliant practice and revenue integrity across the organization.

2. Workforce Pressures Are Elevating Physician Advisor Impact 

Staffing shortages and increasing administrative workload continue to place significant demands on hospital operations and clinical teams. Physician Advisors strengthen appropriate patient status decisions, enabling clinicians to prioritize patient care while clarifying when additional documentation is needed to accurately support inpatient medical necessity and safeguard hospital revenue. Brundage Group’s collaborative model integrates physician advisor support into existing organizational UM workflows; strengthens clinical and operational relationships; and serves as an extension of your organization.

3. Technology Requires Expert Oversight 

Hospitals continue to deploy automation and real-time decision support to manage growing denial pressure. However, technology alone cannot keep pace with shifting payer rules. In 2026, Physician Advisors play a critical revenue cycle oversight role, ensuring UM workflows remain clinically credible, compliant, and aligned to system goals. Brundage Group brings together expert reviewers with the right level of automation to maximize efficiency and deliver measurable outcomes.

Planning for the Future

As the demands on utilization management, documentation integrity, and denial prevention continue to intensify in 2026, external Physician Advisor support is becoming indispensable. Many organizations lack internal capacity, specialized expertise, or real-time coverage needed to navigate continuously evolving payer requirements and growing denial volumes.

Partnering with Brundage Group’s Physician Advisor team provides immediate access to national experience, consistent availability, and proven workflows that elevate performance across the UM function. Brundage Group delivers this support with a model designed to integrate seamlessly with revenue cycle workflows, protect revenue, and ensure compliance in a landscape that is only growing more complex.

The post Physician Advisor Trends Defining 2026  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Balancing Accuracy with Ethics 

Ethical CDI is the foundation of effective documentation. This means issuing queries not only when documentation increases reimbursement but also when may result in lower reimbursement. By maintaining this balance, hospitals safeguard both compliance and integrity, ensuring that documentation accurately reflects hospital resources and patient acuity rather than revenue alone. 

Leveraging Expert Physician Advisor Support 

2026 brings greater complexity in payer requirements and utilization management. External Physician Advisor support has never been more critical. Partnering with an experienced team provides hospitals with national expertise, real-time coverage, and consistent guidance, strengthening internal CDI, and Utilization Management (UM) teams while protecting revenue. 

Harnessing Technology Without Sacrificing Accuracy 

Automation and real-time workflows help streamline CDI, but technology cannot replace clinical judgment. Our approach combines innovative technology with expert review, ensuring queries are appropriate, documentation is compliant, coding is precise and aligned to support accurate DRG assignments, and workflow efficiency is optimized. 

Looking Ahead 

This year, hospitals that prioritize an ethical, accurate, and comprehensive CDI approach will be best positioned to navigate complex reimbursement challenges, reduce denials, and support clinicians effectively. Brundage Group is committed to partnering with organizations to deliver CDI solutions that are compliant, actionable, and that integrated seamlessly with existing revenue cycle workflows, driving measurable impact in 2026 and beyond. 

The post 2026 Goals for CDI and Physician Advisor Collaboration  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Our Physician Advisors and support teams work directly with your teams to deliver real-time support in Clinical Documentation Improvement (CDI), denial management, and medical necessity reviews. Whether it’s a documentation clarification, complex case review, or appeal support, we help strengthen compliance and protect revenue every single day.

At Brundage Group, we’re more than a firm; we’re your trusted partner in enhancing clinical accuracy and operational performance to ensure you capture the revenue you have already earned for the quality care you deliver.

The post Trusted Hospital Support Every Day appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The shift in who performs the reviews has major implications for hospitals, especially regarding compliance, prepayment scrutiny, and financial exposure.

What This Change Means for Hospitals

Under the new process, MACs will manage short-stay reviews with a more data-driven, prepayment focus. That means hospitals could see an increase in review frequency and more targeted audit activity based on billing trends.

Here’s what you can expect:

• Reviews will be prepayment, not post-payment, which can delay reimbursement if documentation is incomplete or unclear.
• MACs will use data analytics to identify hospitals with billing patterns that differ from peer benchmarks.
• The two-midnight rule remains the guiding standard for inpatient payment eligibility.
• Hospital stays longer than two midnights after formal admission are presumed reasonable and necessary for Part A payment.
• Shorter stays will remain under the microscope, particularly when data suggests potential overuse or noncompliance.

With MACs assuming responsibility for these reviews, the takeaway is clear: hospitals must ensure a robust, proactive short stay review process to stay compliant and protect revenue.

Why Certus Radar Is the Right Solution—Right Now

Certus Radar Automated Medicare Short Stay (Self-Denial) Solution helps hospitals manage the complexities of short stay compliance. Given the September 2025 transition, its value is greater than ever.

Certus Radar automates the review and self-denial process, helping hospitals identify, assess, and correct short stay cases before billing—minimizing risk and supporting accurate patient status determination.

How Certus Radar Protects Your Hospital

Ensure CMS Compliance: Stay aligned with CMS requirements, including the two-midnight rule and self-denial/rebilling pathways, even under MAC review.

Reduce Denial Risk: Identify short stay cases proactively to prevent costly denials, reduce administrative burden, and protect reimbursement.

Strengthen Audit Readiness: Prepare for MAC, RAC, and TPE reviews with better documentation accuracy and consistent prebilling review processes.

Support Patient Confidence: Accurate status and billing decisions to prevent confusion, unexpected costs, and downstream appeals—supporting a better patient experience.

Staying Ahead of MAC Oversight

The transition to MAC-led short stay reviews signals a more targeted, data-informed oversight era. Hospitals that rely on manual or fragmented review processes will face a greater risk of prepayment denials and audit delays.

With Certus Radar, your organization gains the automation, visibility, and assurance needed to stay compliant, reduce risk, and stay off the radar.

The post You Need Certus Radar™ to Stay Off the Radar appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Nationwide revenue cycle solutions provider helps hospitals navigate the complexities of clinical revenue cycle management.  

Tampa, Fla. – November 17, 2025

Hospitals received a brief reprieve from Aetna’s Level of Severity Inpatient Policy that applies to their Medicare Advantage (MA) products for provider contracts paid on Diagnosis Related Groups (DRGs) and Medicare Allowable payment methodologies. The implementation date has been moved to January 1, 2026, from November 15, 2025. This is not the update the hospital industry was hoping for as opposition to this policy has been submitted to the Centers for Medicare and Medicaid (CMS) as well as top administration officials.  

Aetna’s Level of Severity Payment Policy 

Under this new policy, Aetna is unilaterally imposing a Five Midnight Rule for contracted providers. Urgent and emergent hospital stays of one (1) midnight and greater with a valid inpatient admission order will be authorized as an inpatient admission; however, some claims may be paid at a reduced rate. This is in direct conflict with the Medicare Two-Midnight Rule that uses a two-midnight threshold to support inpatient admissions. Additionally, severity is already considered within the inpatient payment methodology for traditional Medicare beneficiaries due to the nature of the Medicare Severity Diagnosis Related Group (MS-DRG) methodology where additional payments are made for patients with diagnoses classified as complications/comorbidities (CCs) or major complications/comorbidities (MCCs).    

Brundage Group’s Perspective 

Aetna’s unilateral decision to implement a Five-Midnight Rule could have significant financial consequences for hospitals. A rate similar to what is paid for observation services is unlikely to cover hospital expenses associated with an inpatient visit that crosses two or more midnights. MA organizations are reimbursed annually based on the expected resources needed to treat a beneficiary as determined by a variety of factors including billed diagnoses that map to CMS Hierarchical Condition Categories (HCC). CMS may need to restructure their MA payment methods to reflect Aetna’s lower inpatient cost under this new strategy. This marks a major shift from the current reimbursement structure, increasing hospitals’ risk of revenue loss amid the challenges of the “One Big Beautiful Bill.”    

Medicare Regulations Applicable to Medicare Advantage (MA) Plans 

Aetna has made the calculation that referring to this as a “payment policy” will allow them to implement coverage criteria more restrictive than what is allowable under traditional Medicare. Aetna claims their policy is compliant because “while CMS regulates inpatient coverage determinations, it does not dictate payment terms for contracted providers.” Although this statement appears in federal regulations, it is taken out of context and is being misinterpreted by Aetna.  

Key excerpts from the Contract Year 2024 Medicare Program Update and other federal regulations that demonstrate Aetna’s Five Midnight Rule violates federal regulations.  

1. When determining if Traditional Medicare criteria apply in MA, it is irrelevant whether they are classified as coverage or payment rules, both address the scope of items and services for which benefits are available under Parts A and B.  
2. As finalized in § 422.101(b)(2), MA plans must comply with general coverage and benefit conditions included in Traditional Medicare laws, unless superseded by laws applicable to MA plans. 
   • “This includes criteria for determining whether an item or service is a benefit available under Traditional Medicare, such as payment criteria for inpatient admissions at 42 CFR 412.3” 
   • “Services and procedures that the Secretary designates as requiring inpatient care under 42 CFR 419.22(n)” 
   • “MA plans may not use InterQual or MCG criteria, or similar products, to change coverage or payment criteria already established under Traditional Medicare laws.”  
3. We [CMS] acknowledge that 412.3 is a payment rule for Medicare FFS, however, providing payment for an item or service is one way that MA organizations provide coverage for benefits.  
4. CMS plans to codify existing policy at § 422.101(c)(1)(i)(C) that MA organizations consider the enrollee’s medical history (for example, diagnoses, conditions, functional status), physician recommendations, and clinical notes.  

Appeal Rights under Aetna’s Five Midnight Rule  

Under the new process hospitals submit clinical information within 24 hours of notification. Aetna will perform an initial severity review, “the payment level (high or low level of severity) is based on the number of days the patient is in the hospital and not on the days authorized.” Providers will receive written notification of the inpatient authorization for 7 days and the severity decision.  

The new policy does not allow “peer to peer” reviews since they are not issuing an inpatient authorization denial for these claims. Instead, if a hospital disagrees with the severity determination they can:  

1. Request (via fax) within 7 business days of the date of the decision notification and before the claim is submitted that Aetna review the case again with additional supporting clinical information.  
2. Request (by phone) a severity discussion with a medical director within 14 calendar days from the date of the decision and before the claim has been submitted.  
3. Claims impacted by the severity payment policy will receive the following electronic remittance advice from Aetna: Payment based on an appropriate level of care. After the claim is paid, hospitals retain their contractual right to dispute the level of payment.  

Next Steps 

Hospitals and health systems must continue challenging MA plans like Aetna that attempt to unilaterally redefine federal reimbursement methods. Aetna’s policy exemplifies how MA plans seek to bypass Medicare regulations, underscoring the need for vigilance against payers imposing payment requirements inconsistent with federal rules.

Aetna claims their contracts allow them to “introduce and implement payment policies,” and that “providers agree to comply with policies that Aetna may implement from time to time.” Hospitals should review their Aetna contracts, as this may create individual legal considerations unless federal guidance clarifies the issue.

The post Aetna’s Unilateral Decision to Implement a Five Midnight Rule appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

When the clinical indicators listed in a query don’t support the response options, it becomes vulnerable to denial as a noncompliant or leading query. 

In this edition of Query IQ, we examine a real example in which sepsis was included as a query option without adequate clinical support, resulting in a denial for “introducing an undocumented diagnosis.” 

What the Guideline Says 

According to the 2022 AHIMA/ACDIS Query Brief: 

Compliant Query Guidelines (Page 6) 

II. Diagnosis answer options that are not already documented in the health record must be supported by clinical indicators sourced from the medical record. These clinical indicators must be included within the query.   

What the Guideline Means 

Payers often misinterpret this guideline to mean that an undocumented diagnosis may never be presented as a query option. However, that is not what the guideline means. The above guideline means that if the documentation has clinical indicators to support a query, the condition may be presented as a query option, even if the actual condition is not yet documented.   

 CDI work is a lot like detective work, with one key difference — you can search for clues, but you can’t plant them at the crime scene.  You can only ask about the diagnosis if the “clues” are already there — evidence such as abnormal diagnostics, or treatment without an associated diagnosis. If offering a diagnosis as a query answer option without enough clinical support, you’re not solving the case — you’re framing it.   

 Here’s an example we found… 

The Quirky Query  

Based on documentation in the medical record, this patient is being treated for right lower extremity cellulitis. This patient is status post liver transplant on immunosuppressive therapy. 

The following are also documented in the medical record: 

• Platelets = 88 on xx/xx/xx 

Based on your medical judgment, can you further clarify the cause of these findings such as: 

• Sepsis 

• A localized infection only (cellulitis, right lower extremity) 

• Another condition (please specify) 

What went wrong?  

You may have spotted it right away! Sepsis criteria were weak at best — and the patient had clear underlying liver disease, including post-liver transplantation. Thrombocytopenia in this setting is more likely related to baseline pathology. Listing sepsis as a response option introduced a new diagnosis without support, making the query noncompliant. 

The Payer Perspective 

Most payers rely on Sepsis-3 criteria, which include: 

• Infection 

• A SOFA score increase ≥2 (organ dysfunction directly attributable to infection) 

Many payers take it even further, applying interpretations not directly found in sepsis literature. For instance, they may require that organ dysfunction be “remote” from the site of infection. In other words, they will not apply SOFA criteria if organ dysfunction could otherwise be attributable to a chronic condition. For example, they will routinely discount: 

• P/F ratio abnormalities if sepsis is due to pneumonia 

• Elevated creatinine if the patient has CKD 

• Elevated bilirubin if the patient has chronic liver disease 

• And yes — thrombocytopenia in a post-transplant liver recipient 

Step Away from the Query 

 In this case, the query-based denial was legit. There was no compliant way to introduce sepsis as a diagnosis option. The clinical indicators — including the patient’s immunosuppressed state and platelet count of 88 — may have triggered a second look by the CDI, but without documentation linking the thrombocytopenia to infection, a query for sepsis would be speculative at best. In fact, this may be viewed as a fishing expedition! 

Final Takeaway 

To compliantly introduce a diagnosis in a query, the indicators must clearly support it. The organ dysfunction must be attributed AT LEAST IN PART to infection to pass scrutiny and to be compliant.  

The post Query IQ: When Clinical Indicators Don’t Match the Diagnosis  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

That alignment is achieved through strong Revenue Integrity. 

What Is Revenue Integrity? 

Revenue Integrity is the coordinated effort that ensures hospitals’ services are accurately documented, coded, charged, and reimbursed. 

It combines clinical, coding, and financial operations to safeguard revenue while maintaining compliance and transparency. 

A strong program focuses on: 

• Complete and accurate clinical documentation 

• Compliant patient status 

• Correct coding and charge capture 

• Timely, compliant billing practices 

• Ongoing education and performance monitoring 

Revenue Integrity is not just a finance function — it’s a collaborative discipline that connect providers, CDI specialists, coders, UM nurses, case manager, denials specialists, and revenue cycle leaders around a common goal: ensuring care is accurately represented and appropriately reimbursed. 

Why Hospitals Need Revenue Integrity 

Hospitals today face rising denial rates, tightening margins, and growing pressure to demonstrate medical necessity and ensure compliant coding for inpatient claims. A focus on Revenue Integrity helps protect both clinical and financial performance by ensuring that every service provided is accurately documented, coded, and reimbursed. 

Hospitals that prioritize Revenue Integrity gain measurable advantages: 

• Financial sustainability: Prevents revenue leakage caused by documentation gaps, coding errors, and missed charges. 

• Denial prevention: Through targeted pre-bill review of claims at risk to be denied. Ensure compliant capture of missed diagnosis codes to strengthen claims from the start, reducing costly appeals and rework. 

• Compliance confidence: Aligns documentation and billing practices with regulatory requirements and institutional clinical standards to defend against payer denials. 

• Data accuracy: Produces reliable information for forecasting, benchmarking, and strategic decisions. 

• Cross-team collaboration: Connects clinical, CDI, coding, and finance teams around a shared goal- accurate representation of patient care. 

With Revenue Integrity in place, hospitals can focus on what matters most: delivering quality care supported by a financially sound foundation. 

The Role of Physician Advisors in Revenue Integrity 

At Brundage Group, we know that Revenue Integrity starts with clinical accuracy. 

Our Physician Advisors partner with hospitals to: 

• Strengthen medical necessity documentation 

• Support denial prevention and appeals 

• Educate providers on documentation best practices 

• Align CDI and coding teams for accurate and defensible claims to reduce revenue leakage 

Hospitals protect reimbursement, improve compliance, and fully and accurately capture every patient’s story by integrating clinical expertise into the revenue cycle. 

The Bottom Line 

Revenue Integrity doesn’t just protect revenue – it preserves the integrity of care itself. 

When hospitals bridge the gap between clinical reality and financial representation, they create a sustainable foundation for quality and fiscal resilience. 

Partner with Brundage Group 

Brundage Group helps hospitals strengthen Revenue Integrity by aligning clinical expertise with revenue cycle strategy. Our Physician Advisors and CDI experts work alongside your staff to ensure compliance with correct patient status, identify documentation gaps, reduce denials, and ensure every claim reflects the complexity of patient care your team has provided. 

The post What Revenue Integrity Means in 2026  appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

• The Hospital Readmission Reduction Program (HRRP)
• The Hospital Inpatient Quality Reporting Program (IQR)

The Hospital Inpatient Quality Program (IQR) includes a hybrid hospital-wide all-cause readmission measure (HWR). A hybrid measure incorporates both data pulled directly from the electronic medical record (EMR) and claims data, which is used to define the measure population.

HWR uses core clinical data elements (CCDE) from the EMR, such as laboratory tests and vital signs. This data will be used to improve case mix risk adjustment in conjunction with condition categories that are part of the Hierarchical Condition Categories methodology used to determine CMS payments to MA (Medicare Advantage) plans.

Like the HRRP measures, all unplanned readmissions are included regardless of cause. The HWR measure also uses the same algorithm as the HRRP to determine an unplanned readmission.

Core Clinical Data Elements

Abstraction of core clinical data elements will be automated through the EMR. Measure logic will extract the first set of HWR-specific CCDE differently for patients who receive hospital services prior to admission and those who are direct admits.

• If the patient was a direct admission, the logic supports extraction of the FIRST resulted.
  • Vital signs within 2 hours after the start of the inpatient admission.
  • Laboratory tests within 24 hours after the start of the inpatient admission.
• If the patient has values captured prior to admission, the logic supports extraction of the FIRST resulted vital signs and laboratory tests within 24 hours PRIOR to the start of the inpatient admission.

The specific values that will be extracted from the EMR, which varies by specialty cohort, include:

• Bicarbonate
• Creatinine
• Glucose
• Heart rate
• Hematocrit
• Oxygen saturation (by pulse oximetry)
• Potassium
• Respiratory rate
• Sodium
• Systolic blood pressure
• Temperature
• Weight
• White blood cell count

HWR Exclusions

This measure is different than those included in the HRRP because it is not limited to a few diagnoses or procedures. Potentially all Medicare patients could be included in the population unless one of the following exclusion criteria are met:

• Discharged against medical advice.
• The patient expires during the indexed admission.
• Admitted for:
  • Primary psychiatric diagnoses
  • Rehabilitation
  • Medical treatment of cancer
  • With a principal diagnosis of code of COVID-19 or a secondary diagnosis code of COVID-19 that is present on admission claim.
• Transferred from one short-term acute care hospital (STAC) to another.
  • Only the last admission in a series of transfers eligible for inclusion in the cohort so the measure will be associated with the receiving hospital.

Patients who have an unplanned readmission and expired within 30 days of discharge from the indexed admission will be included as long as they meet criteria.

Specialty Cohorts

A predicted readmission rate is calculated by cohort, which is then divided by the expected readmission rate resulting in a standardized readmission ratio (SRR) for each cohort. The cohorts are:

• Cardiorespiratory
• Cardiovascular
• Medicine
• Neurology
• Surgery/gynecology

The volume-weighted geometric mean of SRR for each cohort results in a combined SRR, which is compared to the national readmission rate to procedure the risk-standardized readmission rate (RSRR).

CMS assigns hospitals to a performance category for HWR by comparing each hospital’s RSRR interval estimate to the national observed readmission rate as follows:

• “Better than the National Rate” if the entire 95% interval estimate surrounding the hospital’s rate is lower than the national observed readmission rate.
• “No Different than the National Rate” if the 95% interval estimate surrounding the hospital’s rate includes the national observed readmission rate.
• “Worse than the National Rate” if the entire 95% interval estimate surrounding the hospital’s rate is higher than the national observed readmission rate.

There are several measures included within the IQR. Overall hospital performance under the IQR program can result in:

• Hospitals receiving full Annual Payment Update (APU) – hospitals that satisfactorily met the requirements.
• Hospitals not receiving full APU – hospitals that did not satisfactorily meet criteria or do not participate receive a reduction by one-fourth of the applicable market basket update.

The CMS annual market basket update payment refers to the adjustments made to Medicare payments based on the cost-of-living increases. The increase in IPPS operating payment rates for general acute care hospitals that successfully participate in the IQR program and are meaningful electronic health record users under the Medicare Promoting Interoperability Program is 2.6% for FY 2026.

The post Hospital-Wide Readmission Measure: Hospital Inpatient Quality Reporting (IQR) appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

In our last issue of Query IQ, we talked about approaching queries with a scientific mindset: Start with a hypothesis, build your case with solid clinical evidence, and structure your query accordingly. Sounds simple, right? Well… not exactly. 

Crafting a query that’s clear, compliant, and clinically meaningful is both an art and a science. I’ve got the science part down — hypothesizing and digging through data is second nature. But when it comes to the art of structuring a truly compliant, well-balanced query, I often turn to my colleague Cheryl Ericson, Director of UM and CDI at Brundage Group. 

In this edition of Query IQ, Cheryl and I discuss how to craft a clean, compliant, and non-leading query in a real-world scenario where I hesitated to recommend a query for fear it could appear leading. 

 The Scenario: When the Clues Are There, but the Diagnosis Isn’t 

A patient presented without chest pain but had a notable rise in troponin values, peaking at over 1000. Imaging showed anteroseptal hypokinesis on echo. The clinical picture appeared to meet criteria for a Type 2 NSTEMI, but instead the provider documented on the Discharge Summary: “Elevated troponin… suspected to be nonischemic myocardial injury related to sepsis… further cardiac workup deferred to outpatient.” 
 
From a coding perspective, this is a self-inflicted wound! The criteria for Type 2 NSTEMI were met, but the diagnosis was documented as something else; a completely different ICD-10 code! 

Clinical Criteria for Type 2 NSTEMI: 

According to the Fourth Universal Definition of Myocardial Infarction, Type 2 MI requires: 

Plus at least one of the following: 

In this case, the troponin trend and anteroseptal hypokinesis fulfill the criteria for Type 2 NSTEMI. But how do I pose that question when the provider has already documented non-ischemic myocardial injury-on the Discharge Summary? 

Putting on my payer hat for a moment, I can already hear the argument: “Why ask the question? The provider already documented something else.” Call it a little PTSD from all the query-related denials — but it’s exactly this kind of scenario that makes compliant query structure so important. 

Why a Query Is Appropriate in this Scenario 

In this scenario we could apply the inpatient coding guideline regarding uncertain diagnoses,  

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. 

Or we could query the provider to see if he/she is comfortable making a definitive diagnosis. According to the Guidelines for Achieving a Compliant Query Practice (2022 Update), ambiguous documentation, defined as “documentation that fails to reflect the provider’s intent, impacts the clinical scenario (e.g., diagnoses, complications, quality of care issues), the accuracy of code assignment, and/or the ability to assign a code,” is a general query convention. In this case, we are not sure the current documentation accurately reflects the clinical scenario; therefore, querying is appropriate.  

A query is also supported by coding guidelines because the provider documented “elevated troponin” which is an abnormal finding. In this example, we know additional testing was ordered, an ECHO, which found anteroseptal hypokinesis. The Abnormal Finding guideline states, “If the findings are outside the normal range and the provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.” The discharge documentation does not appear to fully address this significant abnormal finding; therefore, a query is appropriate.  

Clinically, there is conflicting documentation in the health record. It is not uncommon for a diagnosis to be validated with additional investigation, but in this example, the documentation addressing the high troponin levels was uncertain. Additionally, providers documented the possibility of both “myocardial injury” and “nonischemic myocardial injury” injury. The code set assumes “myocardial injury” to be the same as “nonischemic myocardial injury” because “nonischemic” is an unnecessary modifier but clinically, we cannot assume the intent of the provider. The American Journal of Medicine (August 2022) states, “Diagnosis and therapy of type 1 MI are well understood and usually present no problem to the physician.  The clinical scenarios leading to type 2 MI and non-ischemic myocardial injury are, however, often fraught with greater degrees of uncertainty.” This report follows a 2019 article in JAMA Cardiology that found, “Patients with nonischemic myocardial injury frequently receive incorrect diagnoses and are billed as having T2MI.” It is appropriate to query when there is conflicting documentation in the health record. This is where having access to a physician advisor is helpful because they can assist with determining if the clinical scenario is accurately represented by the current documentation. Remember, we must not only rely on coding conventions and guidelines, but also continuity of the clinical scenario.  

The Query 

Because querying is somewhat subjective, query professionals and payers may disagree what is necessary for a query to be compliant with industry guidance. Payers may try to challenge a simple, concise query but being clear and concise is a general query guideline.  

Most providers prefer when the query begins with the question because not all providers need to review the included clinical indicators depending on their familiarity with the patient. It is also not necessary to ask the provider to use their independent judgment, the provider is legally responsible for establishing diagnoses. Just like health information professionals, medical professionals must abide by a code of ethics; however, providers must also be weary of liability so there is even more incentive for a provider to accurately diagnosis and treat a patient.  

Based on the clinical indicators presented below, can the conflicting documentation of in the health record be further clarified as   
( ) Type 2 NSTEMI  
( ) Non-ischemic myocardial injury  
( ) Other (please specify): _________________

Clinical Indicators from the Medical Record

The post Query IQ: Clarify Without Leading appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Nationwide revenue cycle solutions provider helps hospitals navigate the complexities of clinical revenue cycle management.  

Tampa, Fla. – [August 14, 2025] 

Beginning November 15, 2025, Aetna will implement a New Medicare Advantage Inpatient Policy.

What Hospitals Need to Know

What’s Changing

Aetna will implement a “level of severity inpatient payment policy” that changes how urgent and emergent inpatient claims are paid:

Why It Matters

Our Assessment

This policy avoids issuing formal denials by reclassifying coverage decisions as payment adjustments. This will prevent hospitals from appealing through traditional medical necessity review channels — undermining revenue integrity and patient protections.

What Hospitals Should Do Now

Review Aetna Contracts
Examine language around payment adjustments, denials, and severity-based rates.
Amend Contracts
Require payer adherence to CMS regulations as outlined in the CMS Medicare Advantage and Part D Final Rule 4201-F.
Require formal denials for any inpatient stays paid at a reduced rate. Define and limit payer adjustment authority.
Contact Aetna
Reach out to your payer representative and voice your concerns.
Advocate
Work with AHA (American Hospital Association), CMS, and state regulators to equate “severity” with “medical necessity” for regulatory oversight.
Educate Patients
Notify Aetna MA beneficiaries about potential financial impacts and appeal rights.
Encourage Aetna MA beneficiaries to file a complaint with CMS if patient rights are compromised.

Key Takeaway

If left unchallenged, this policy could set a precedent for Medicare Advantage plans to unilaterally reduce payments without transparency, eroding clinical authority and hospital sustainability.

We’ve prepared an overview detailing what this means for your hospital, your contracts, and your patients — and the steps you can take now.

The post Aetna’s New Medicare Advantage Inpatient Policy and Its Impact on Hospitals and Patients appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

But here’s the hard truth: technology alone isn’t enough.

Hospitals need more than data; they need direction, actionable intelligence, and decisions. That’s why Brundage Group takes a different approach: physician-led, tech-enabled.

The Limits of Technology in Revenue Cycle Management

Technology is a powerful enabler, but it often falls short without clinical insight. Too many hospitals invest in tools that generate reports but don’t drive change.

Why?

Because:

• Data without interpretation leads to information overload
• Insights without action fall flat
• Platforms without people don’t solve problems; they accelerate them

Technology can highlight opportunities, but it takes clinical and operational expertise to execute.

When Tech Tools Add Burden Instead of Value

Ironically, some tools meant to streamline processes can create more complexity and workload. We hear this from hospitals all the time.

Why? Because many technology platforms:

• Require more resources to manage, maintain, and monitor
• Rely on clean, structured input data that often doesn’t exist in real-world workflows
• Require ongoing training and change management to be used effectively
• Struggle to integrate with core systems like EMRs, coding platforms, and existing hospital workflows

Instead of reducing noise, they sometimes increase it, creating alert fatigue, dashboards, and questions without clear answers.

When a tool isn’t fully adopted or is poorly aligned with clinical operations, it wastes time, budget, and opportunities.

At Brundage Group, we believe that technology should support people, not vice versa. We pair our products with Physician Advisors who guide your team through adoption, integration, and action.

Why Physician-Led Services Enhance Revenue Capture

At Brundage Group, our Physician Advisors don’t just understand the revenue cycle; they work in it. They know how status determinations, documentation quality, and denial trends play out in the real world.

That means we don’t just identify where revenue is leaking – we guide your team on how to fix it.

From inpatient to observation status, our physician-led approach helps hospitals:

• Improve compliance
• Reduce denial risk
• Capture earned revenue

We bridge the gap between clinical care and financial performance.

How Tech-Enabled Tools Strengthen Strategy

We pair our physician insight with purpose-built, proprietary technology that makes tracking, acting, and improving easier.

Our platforms surfaces real-time opportunities, monitors key metrics, and delivers transparent, actionable feedback to all stakeholders.

With our tech solutions, you can:

• See where documentation or status is falling short
• Track Physician Advisor interventions
• Close the loop between insight and impact

A Closed-Loop Approach: From Opportunity to Resolution

We support the entirerevenue capture and utilization management lifecycle, not just one step.

Here’s how we do it:

Opportunity Identification – Our analytics reveal missed revenue, clinical misalignment, and risk areas.

Intervention & Capture – Physician-led reviews and education correct the course in real time.

Feedback Loop – Ongoing reporting ensures your teams learn, adapt, and scale success.

No more disconnected data. No more siloed teams. Just proven impact -from start to finish.

The post Tech Alone Can’t Fix Your Revenue Cycle: How Physician-Led RCM Closes the Gaps appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Nationwide revenue cycle solutions provider helps hospitals navigate the complexities of clinical revenue cycle management.  

Tampa, Fla. – August 4, 2025

Brundage Group is proud to announce that Taylor Smith, Vice President of Business Development, and Keith Fulmer, Chief Technology & Information Officer, have been recognized by Becker’s Healthcare as 2025 Up-and-Comers in Health IT and Revenue Cycle Management.

This prestigious list highlights emerging leaders nationwide who are transforming Healthcare through innovation, strategic thinking, and a deep understanding of the evolving landscape. These individuals influence organizational growth, financial performance, and the delivery of high-quality care.

This marks the second consecutive year that Keith Fulmer has earned this national recognition, underscoring his ongoing leadership in driving Brundage Group’s digital transformation and commitment to leveraging technology that improves outcomes and operational efficiency.

Becker’s Healthcare develops the list based on editorial research and peer nominations. Honorees represent a new generation of leaders helping shape the future of healthcare.

Brundage Group congratulates Taylor and Keith on this well-deserved recognition and is honored to have such visionary professionals helping lead the organization forward.

About Brundage Group

Brundage Group is the trusted choice of hospital systems for revenue cycle management solutions. We support hospitals nationwide with customized solutions, including a full suite of physician advisory services, proprietary level of care analytics, and physician-led education to relay quality care. Our programs help hospital organizations break down departmental silos by unifying all departments in the mid-revenue cycle. Learn more at brundagegroup.com. 

For media inquiries, please contact:

Lacey Thompson
Marketing Director, Brundage Group
Email: lthompson@brundagegroup.com

The post Brundage Group Leaders Recognized by Becker’s Healthcare appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

You can spot a templated query a mile away: Overly long, loaded with generic verbiage, or padded with so much irrelevant detail that the actual question gets lost in translation. It’s like going on a scavenger hunt — without a map. 

At the other end of the spectrum is the dropdown-style template with a simple option to “add” a diagnosis code— a format that carries a high risk of denial. 

In this edition of Query IQ, we’re exploring how to make templates work for you, not against you, and how a thoughtful, concise approach can elevate compliance and clarity and invite fewer query-based denials. 

Customize or Compromise 

Templates are meant to be edited and customized, yet far too often, we see them left unaltered. For example, only a few clinical indicator prompts are filled with copy-and-paste data or irrelevant query options   needlessly take up space on the query form. The ACDIS/AHIMA query practice brief states query options need to be supported by the clinical evidence.  More often than not, pneumonia templates list every possible pneumonia etiology under the sun without clear insight into why the author is posing the question. 

The dropdown-style template with a simple option to “add” a diagnosis code must be carefully edited and tailored to the clinical scenario. Without proper customization, these queries are a compliance risk and may compromise defensibility if the payer denies them. 

Tip: If you’re cutting and pasting or selecting dropdown options more than you are clinically clarifying, it’s time to revise your strategy. 

Queries Should Be Clinically Grounded and Conscise

Think like a scientist. Hassan Rao, MD, Associate Chief Medical Officer and VP, DRG Integrity Service Line at Brundage Group, states that every query you write should reflect a clear hypothesis: Was sepsis present on admission? Could encephalopathy be further clarified as metabolic? Can the labs and clinical context be further clarified as AKI? Is fluid overload an indicator of an acute exacerbation of systolic heart failure? Having clear intent while writing the query allows you to focus on the appropriate clinical indicators and options to provide. The best and easiest queries for providers to answer are the ones that are succinct and concise. While it may not be possible for every clinical scenario, being able to craft a concise query is the mark of a skilled CDI/coder.

Be genuinely curious! 

The structure of your query should match its purpose: 

• If you’re trying to validate something (e.g., sepsis), clearly organize your indicators to reflect the hypothesis and why you’re questioning it. 

• If you’re trying to clarify an omitted diagnosis, be sure the clinical indicators are relevant to the query options and the connection to your hypothesis is clear. Without that focused intent, queries can feel like fishing expeditions — and that opens the door to accusations of authoring a leading query and potential denials. 

Template Truth: One Size Doesn’t Fit All 

You need different templates or structures depending on the scenario: 

• Clinical validation – Keep it tight, focused, and explicitly present supporting and conflicting evidence for the diagnosis in question. 

• Missed diagnosis – Lay out the timeline and clinical indicators and ask a multiple-choice question that reflects your clinical reasoning. (Don’t forget to include the option of Other!) 

Templates are tools — but they should be used with purpose and precision, not as fill-in-the-blank forms where ICD-10 codes are dropped in willy-nilly. 

Compliance is Still King 

It is an art and a science to strike a balance that is neither leading nor vague. But it’s much easier for a provider to understand your intent if you frame the clinical picture clearly: 

“Despite normal vitals and no documented organ dysfunction, sepsis was documented. Please clarify…” 

That’s not leading — that’s thoughtful. And that’s the difference between a query that sparks a response and one that gets ignored (or worse, denied). 

5 Best Practices for Templated Queries 

1. Edit the Template – Always customize. If something doesn’t apply, remove it. If something is missing, add it.  

2. Lead with Purpose – What are you hypothesizing? Write with that intent in mind. 

3. Be Concise – More words ≠ more clarity. Use bullets, short sentences, and clean formatting. 

4. Frame the Hypothesis – Demonstrate clinical reasoning that aligns with the query’s intent and makes sense with the options provided. 

5. Match Structure to Purpose – The format of your query should reflect what you’re trying to accomplish, whether validating a diagnosis or clarifying documentation. 

The post Query IQ: Are Your Query Templates Friend or Foe? appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

As healthcare leaders look to the second half of 2025, many are asking a crucial question: How can we redesign our work to drive better outcomes for patients and the bottom line?

McKinsey’s recent article, Heartbeat of Health: Reimagining the Healthcare Workforce of the Future, explores how systems can respond to increasing complexity, workforce shortages, and rising costs. However, what may not be evident at first glance is how these workforce changes are tied directly to clinical revenue cycle performance.

Here’s how we see it:

1. Redesigning Care Models Can Improve Revenue Integrity

The McKinsey report underscores the importance of shifting care and administrative responsibilities to more appropriate roles and settings. For Revenue Cycle Management (RCM), this means removing friction where it matters most: documentation, status assignment, and utilization review. When the right clinical roles are empowered to work at the top of their license, hospitals can improve the accuracy and completeness of documentation, avoid missed revenue opportunities, and strengthen compliance.

At Brundage Group, we support this with proven Physician Advisory models that reduce administrative burden while improving the quality of medical necessity documentation.

2. Technology and Automation Are Not Optional, They’re Foundational

As automation takes center stage in the workforce of the future, healthcare organizations must look for ways to apply intelligent tools across the clinical revenue cycle. From real-time analytics to query tracking systems, automation can reduce denials, surface insights faster, and support more proactive compliance efforts.

With solutions like Certus Beacon, Brundage Group empowers hospitals to use data to respond accordingly.

3. The Right People Must Be Focused on High-Value Work

In a constrained labor market, allocating your internal expertise wisely is essential. Healthcare leaders must ask: Are our clinical experts spending time where they can drive the most impact? Too often, in-house teams are stretched thin, pulled into administrative tasks that distract from critical care and revenue-related decisions.

Outsourcing Physician Advisor support to Brundage Group allows hospitals to shift high-impact utilization management tasks such as medical necessity reviews, status determinations, and denial prevention to a team of dedicated experts. This frees internal clinicians to focus on patient care while improving compliance and reimbursement outcomes.

By aligning the right expertise to the right work, Brundage Group helps organizations strengthen the clinical revenue cycle without increasing internal burden.

The Bottom Line

Accordingly, the future of healthcare work isn’t just about filling roles; it’s about redesigning how we deliver care and capture value. Brundage Group supports hospitals with clinical insights, technology-enabled services, and a commitment to helping them capture earned revenue for the care they deliver.

The post Reimagining the Healthcare Workforce appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

In a healthcare environment where data breaches are costly and operational inefficiencies impact patient care, your integration partner must do more than connect systems. They must protect them.

Built on Trust, Backed by Certification

Every solution we deliver, from clinical analytics to physician advisory services, is backed by HITRUST certification. Whether you leverage Certus Beacon for revenue integrity insights, Certus Radar for real-time performance monitoring, or Certus Connect for EMR integration, you can trust that your data is protected by industry-leading security protocols.

In a healthcare landscape where data breaches are costly, and integration gaps can stall patient care, Brundage Group offers more than functionality. We offer confidence.

Interoperability Without IT Headache

Our products are designed with interoperability in mind. With minimal lift from your internal teams, Brundage Group’s suite of solutions integrates with your EMR and other core systems. From real-time case reviews to documentation support and compliance analytics, our solutions streamline processes and drive measurable outcomes.

Why HITRUST Certification Matters

Security isn’t a value-add; it’s a requirement. HITRUST certification verifies that our systems comply with the most stringent frameworks in healthcare, including:

• HIPAA (Health Insurance Portability and Accountability Act)
• NIST (National Institute of Standards and Technology)
• And others

This means your organization can confidently leverage Brundage Group products, knowing that your data is secure, your workflows are compliant, and your patients are protected.

Secure. Scalable. Aligned with Your Mission.

From rapid implementation to long-term impact, Brundage Group’s HITRUST-certified solutions are built to support the needs of today’s healthcare leaders. Whether you’re improving documentation quality, reducing denials, or optimizing case management, our tools work together securely to elevate performance.

Power a Smart, Safe Revenue Cycle

With HITRUST-certified security across every solution, Brundage Group delivers the confidence and connection your team needs to move faster and more secure.

The post HITRUST Certified: Our Approach to Secure Revenue Cycle Integration appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

When Payers Demand More Than What’s Required

A query walks into a hospital, and the payer says, “Sorry, we don’t serve your kind here without source documentation citations.”

It’s a joke — but lately, most query-related denials are.

We recently received a denial claiming that an otherwise compliant query was invalid because it didn’t specify the exact location of clinical indicators in the record. And just in case that argument didn’t hold up, the payer added a second layer — stating the condition couldn’t be reported because it wasn’t treated.

The payer stated:

“Upon review of the medical record and the available physician query form, there was no citation or location of clinical indicators, and it was not compliant per AHIMA query guideline practice. The query did not have treatment for non-ischemic myocardial injury.” This reflects a growing trend: Misapplying industry guidance to justify denials. For context, this is what The American Health Information Management Association – Association of Clinical Documentation Integrity Specialists (AHIMA-ACDIS) Practice Brief states regarding citation location of clinical indicators: “Clinical indicators should include a citation of the location found within the health record.”

Denial Debrief: Myocardial Injury Clarification

Here’s the query in question:

This query is being sent for clarification of the following documentation in the medical record:

• ED documentation: The patient presented for evaluation of loss of peripheral vision and headache. Admitted for CVA.
• Cardiology note: Denies chest pain, shortness of breath, dizziness, lightheadedness, syncope.
• Troponin trend: 21 → 40 → 182 → 401
• EKG: Sinus rhythm with nonspecific abnormalities

An ischemic workup was deferred in the acute CVA setting with no ischemic symptoms. Type 2 MI suspected.

Based on your medical judgment, please clarify which, if any, of the following diagnoses apply:

• (X) Non-ischemic Myocardial Injury
• (  ) Type 2 MI due to  _______
• (  ) Other: __________________

The physician selected Non-ischemic Myocardial Injury in response.

The diagnosis was denied despite referencing the ED and cardiology documentation, the source of the clinical indicators, and outlining clear clinical indicators.

Response: Clarification Is the Purpose

This query is both appropriate and compliant. It was issued to clarify whether a suspected diagnosis—Type 2 MI—was ruled in, ruled out, or should be otherwise specified. That intent is fully supported by the 2022 AHIMA/ACDIS Practice Brief, which states that compliant queries may be used:

• To establish clinically supported acuity or specificity of a documented diagnosis to avoid reporting a default or unspecified code
• To determine if a diagnosis is ruled in or ruled out

The denial incorrectly claimed the absence of treatment invalidated the query. Official Coding Guidelines do not require treatment as a required element for capturing a secondary diagnosis and the Practice Brief does not require treatment as a clinical indicator. Valid clinical indicators may also include (among others):

• Evaluation
• Monitoring
• Diagnostics
• Clinical Context

In this case, the troponin trend combined with a lack of ischemic symptoms, and clear documentation of suspected Type 2 MI provided a defensible, clinically sound rationale for clarification.

Additionally, the query clearly sourced the “cardiology note” rendering the payer’s interpretation of the Query Brief invalid.

Final Thought

This denial reflects a broader issue: payers are shifting focus from the clinical appropriateness of a query to technical aspects of query formatting. Industry standards remain unchanged; keep your queries clear, specific, and rooted in the record to withstand scrutiny.

The post Query IQ: Clarifying Clinical Indicators appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

For years, CMI has been used as a key performance metric. But with today’s complex payer mix, shifting regulations, and increased scrutiny on reimbursement, the disconnect between CMI and financial reality is growing. It’s time to ask: Is your hospital relying on an incomplete metric and missing revenue?

What is Case Mix Index (CMI)?

Case mix index (CMI) is an imprecise measure used as a key performance indicator in healthcare for years. Although all payers do not use Medicare Severity Diagnostic Related Groups (MS-DRGs) for payment, most hospitals calculate their CMI for all payers as a benchmark.

CMI is the average relative weight associated with all inpatient MS-DRGs for a specified period. Hospital Chief Financial Officers (CFOs) often use CMI to:

• Measure potential revenue
• Monitor financial performance
• Budgeting and forecasting
• Track the Return on Investment (ROI) for Clinical Documentation Integrity (CDI) efforts

However, CMI is not the comprehensive measure it’s often assumed to be.

Why CMI Is an Incomplete Metric

Several variables beyond documentation and coding practices can impact it CMI, including:

• Volume of inpatient surgical cases
• Hospital service lines
• Inpatient ratio/Utilization Review gatekeeping activities
• Denials resulting in DRG downgrades

Historically, a higher CMI equals financial health; however, many hospitals with a high CMI also have a low or even negative operating margin. Although CMI is associated with concepts like severity of illness (SOI), it does not accurately represent the acuity of the patient population. CMI is based upon a reimbursement methodology that can only stratify similar patients into a maximum of three groups.

The Disconnect: MS-DRG Weight vs. Real-World Cost

MS-DRGs also include a geometric mean length of stay (GMLOS). When patients stay longer than the GMLOS, the hospital may lose money, especially if care extends beyond the intended payment range.

Yet CMI doesn’t capture that nuance. It reflects billed values, not whether those values were fully reimbursed or accurate representations of care delivered.

The Overlooked Impact of Observation Services

Observation status adds even more complexity. Many hospitals don’t factor in the financial implications of prolonged observation stays, which:

• Are outpatient services not reimbursed using MS-DRGs
• Are reimbursed based on a 24-hour benchmark—even if care extends to 48+ hours
• Are not reflected in CMI metrics
• Can result in significant ghost revenue when not properly tracked

Long observation stays frequently cost more than the associated reimbursement, but these losses go unnoticed without a tracking mechanism.

When CMI Gets It Wrong: Real Consequences

Inpatient and outpatient services are paid using different reimbursement methodologies, and time spent receiving care is tracked differently. This causes confusion when observation patients are subsequently admitted for inpatient care one or more days after the start of hospital services. Many electronic health records default to the date of admission, thereby distorting the actual amount of time the patient received hospital services. This can distort:

• CMI accuracy
• GMLOS calculations
• Resource-to-reimbursement alignment

What Hospital Leaders Need Instead

CMI offers a narrow view. Hospitals need comprehensive, real-time visibility into how care is delivered, documented, and reimbursed, especially for high-variability services like observation.

Leaders should invest in tools that:

• Integrate utilization management, documentation, and billing data
• Track patient journeys across all care settings
• Identify where reimbursement falls short of resource expenditure
• Support informed status assignments and reduce revenue leakage

Final Thoughts: Time to Move Beyond CMI

Hospitals need efficient, cohesive technology that supports clinical revenue cycle workflows and monitors their processes’ effectiveness. As CMIs continue to outpace operating margins, hospital leadership needs better ways to track how hospital resources are expended and when payments fail to reflect those services. 

The post What Your CMI Isn’t Telling You appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Have they been guided by experienced colleagues who can protect revenue and navigate denials? Or have they been inadvertently trained by payers, shaped by repeated denials rather than empowered to prevent them?

Even the most capable Physician Advisors may fall short when internal programs lack these supports. Worse yet, leadership often doesn’t realize the shortfall because the missed revenue, compliance risk, and under-captured denials remain invisible.

When structured correctly, this role is a revenue preservation and generation engine. However, when approached as a checkbox or stopgap, it becomes an expensive missed opportunity.

The Hidden Costs of Internal Programs

Many health systems assume “a Physician Advisor is a Physician Advisor.” But that mindset overlooks significant variability in performance and cost:

• Internal Physician Advisors often split time between clinical and UM responsibilities.
• The “cost” of a Physician Advisor generally doesn’t account for the lost revenue as a result of uncovered PTO, training, coverage gaps, or recruitment churn.
• They may lack access to national payer insights, performance benchmarks, and real-time escalation support.

What Makes External Physician Advisors Different?

At Brundage Group, our Physician Advisors:

• Are fully dedicated to UM  or Physician Advisor work (no moonlighting or rounding distractions).
• Operate inside a high-performance infrastructure.
• Use proprietary analytics to identify revenue risks in real-time.
• Are held accountable for measurable results, not just process adherence.

Unlike internal hires, external Physician Advisors can be scaled up, down, or disengaged based on performance without HR complexity.

Strategic, Not Supplemental

Choosing external Physician Advisors isn’t just about filling gaps. It’s a strategic decision to improve:

• Reimbursement — by ensuring correct patient status from the start
• Compliance — by supporting documentation that withstands audits
• Operational efficiency — by enabling quicker decisions and escalations

Our national perspective allows us to detect trends, adapt strategies, and provide clients with regional and national peer benchmarks and insights into payer behavior.

It’s Not Just Who’s in the Seat—It’s What You Put Behind Them

At Brundage Group, our Physician Advisors are:

• Experts in denial prevention and overturn strategies
• Data-driven and proactive
• Unafraid to push back against inappropriate payer tactics
• Skilled at identifying and capturing Ghost Revenue

We’re not incentivized by “win rates;” your financial outcomes and compliance integrity incentivize us.

Internal vs. External: A Snapshot

Bottom Line: Results You Can Measure

Hospitals that partner with Brundage Group routinely see:

• 10 percentage point increase in Inpatient rates
• 10 percentage point improvement in overturn rates
• Millions in additional net revenue annually

We help reframe the Physician Advisor investment, not as a cost center but as a strategic lever for margin protection, compliance assurance, and revenue growth.

The post Physician Advisors Are Not Commodities: A Strategic Look at External Support appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

These dollars are tied to care you’ve already provided but never fully captured, often because of incorrect patient status, insufficient documentation, or missed peer-to-peer escalations. This kind of leakage happens daily in hospitals nationwide, usually without leadership even realizing it.

What Causes Ghost Revenue?

Several systemic and behavioral factors contribute:

• Inappropriate use of Observation for patients who qualify for Inpatient status via medical necessity. A common cause for this is poorly defined escalation criteria for Physician Advisor review for status determinations.
• Under-resourced utilization management teams that lack the time or tools to correct misclassified admissions.
• Over-reliance on scoring tools without human review and strategic intervention.
• Behavioral economics at play in which: teams become conditioned by repeated payer denials and begin to status patients based on what they believe the payer will deny instead of what is medically appropriate.

Here’s the Reality

For an 800-bed academic hospital, even a 1% increase in appropriate Inpatient admissions can add an incremental $1.2 million in annual net income.

That’s not a theory. That’s math.

And it’s the kind of growth that doesn’t require seeing more patients or billing higher charges. It’s about capturing what you’ve already earned, compliantly, accurately, defensibly, and proactively.

How to Claim Your Revenue

Brundage Group’s Physician Advisors are trained and experienced at identifying and correcting these missed opportunities before they become missed revenue. We leverage:

• Proactive documentation support
• Real-time analytics
• Tech-enabled processes
• Deep payer strategy expertise

This combination helps prevent ghost revenue from haunting your bottom line. More importantly, it supports compliance and allows hospitals to bill confidently for the quality care they’ve delivered.

Stop Ghost Revenue in its Tracks

Leadership teams can no longer afford to see Physician Advisor services as optional overhead. When structured correctly, this role becomes powerful engine for both revenue preservation and generation.

The post Ghost Revenue: How to Claim Earned but Unrealized Dollars appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

If your blood pressure spikes every time you read “denied due to query noncompliance,” you’re not alone and certainly not overreacting. Over the last few months, we’ve seen an uptick in query-related denials. 

Sure, in some instances, queries could be of better quality (we’ve all seen that second query sent when the first response wasn’t what someone had hoped for), but let’s be honest: Most of these denials target compliant, well-documented, and clinically sound queries. 

So, what’s going on? 

A recent inclusion in their arsenal is the Guidelines for Achieving a Compliant Query Practice from the American Health Information Management (AHIMA)/Association of Clinical Documentation Integrity Specialists (ACDIS) where some payers are twisting the contents beyond recognition, as if it were written in a yoga manual instead of a legitimate medical record. 

Let’s be clear: this is not a denial based on provider documentation per se.

It’s not a clinical concern for the patient.

It’s a revenue protection strategy by the payer.

Misusing the Query Brief to deny legitimate, clinical diagnoses identified through the query process is not only deceptive but may also be detrimental to hospital reimbursement.

Introducing Query IQ: Your Defense Against Denials

Welcome to Query IQ, an educational series designed to provide you with the tools, real-world query examples, and strategic best practices to defend compliant queries against denial games.

Payers should not rewrite the rules whenever a Major Complication or Comorbidity (MCC) tantalizes them.

Denial Debrief: The “Other” Excuse

Let’s walk through a recent denial example that’s almost too absurd to believe.

The Clinical Scenario

Operation Date: xx-xx-2025

Pre-op Diagnosis: Incarcerated epigastric hernia

Post-op Diagnosis: Strangulated epigastric hernia containing small bowel

Procedures:

• Diagnostic laparoscopy
• Open hernia repair
• Small bowel resection

Pathology Report Highlights:

• Small intestine: Segmental resection with ischemic enteritis
• Hernia sac: Confirmed incarceration

The Query Sent to the Provider

Based on the above, please provide an appropriate diagnosis that supports the clinical indicators, including evaluation, monitoring, and/or treatment:

• Acute ischemic bowel
• Chronic ischemic bowel
• Acute on chronic ischemic bowel

Physician Response: Acute ischemic bowel

Payer Denial: “No option for ‘Other’ was provided.”

Brundage Group Response: Including an “Other” or similar terminology is best practice, but let’s not kid ourselves: This was a clinically specific, well-structured query. The physician was asked to clarify the acuity of the ischemic bowel: Acute or Chronic, thus averting a default or unspecified code.

And guess what?

That’s precisely what the 2022 AHIMA Query Brief supports:

II. When to Query:

“To establish clinically supported acuity or specificity of a documented diagnosis to avoid reporting a default or unspecified code.”

That’s what we did. We avoided the non-specific K55.9 (Unspecified ischemic bowel) in favor of an accurate, more clinically meaningful code.

The Official Coding Guidelines Also Say…

• Use unspecified codes only when more specific documentation isn’t available
• Code to the highest level of specificity — if the info is there, use it

Query IQ Tip: Build Bulletproof Queries

Even when it feels redundant or out of place, always include “Other” or similar terminology in multiple-choice queries. This will not change the clinical truth but will remove a weak excuse for denial.

Think of “Other” as a seatbelt: You can leave it off, but we don’t recommend it, and it is the law!

Coming Up Next in Query IQ

Stay tuned for the next edition, where we’ll tackle the denial that claims: “You didn’t cite clinical indicators correctly.” (Spoiler: we did).

The post Query IQ: The “Other” Denial-When Payers Rewrite the Rules appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Association of Clinical Documentation Integrity Specialists (ACDIS) 2025 is in the books. This was one of the best ACDIS conferences I have attended. Kudos to the conference committee for their selections. The quality of the presentations demonstrates how the Clinical Documentation Integrity (CDI) profession has grown. It is great to see hospital leadership including those who rose through the ranks as former coders or CDIS. Here are some of my key takeaways from the conference.  

Denials Management: A Team Sport

There were many valuable presentations on denials management and the importance of including CDI professionals. I hope attendees are inspired to advocate for inclusion in denials management efforts. Denials management is a team sport that requires coordination among all clinical revenue departments. Documentation and coding practices contribute to medical necessity denials in addition to those that can result in a lower weight Diagnosis Related Group (DRG).  

Robin Sewell, CDIP, CCS, CIC, CPC, CHTS-PW, and I shared our experience with DRG downgrades secondary to payers deeming a query as non-compliant. Many hospitals are unfamiliar with this new payer tactic. My favorite presentation of the conference was, “Clinical Legal Implications of Payer Documentation Integrity Audits,” by Dr. R Kendall Smith, Jr. and Richelle Marting. What made this presentation stand out was Richelle’s perspective as an attorney and Director of Managed Care Contracting. We often tell hospitals to address issues like clinical validation in their payer contracts, but Richelle provided the “how” that we’ve been missing.  

Quality, Access, and the Expanding Role of CDI

Quality was a hot topic as usual. The sessions were a great reminder that not all hospitals are staffed to support identifying diagnoses that risk-adjust quality measures or exclusions. Smaller hospitals may not have access to the same resources as large health systems or academic medical centers and may be at the beginning of their foray into quality. Many of these presentations reaffirmed my belief that at some point, CDI may have subspecialities, like a quality focus because it is difficult for CDI professionals to balance all they are asked to do, “while they are in the record.”  

I was fortunate to present with Penny Jefferson during the conference. As members of the ACDIS regulatory committee, Penny is the chair, we started exploring issues associated with patient admit type and how it impacts performance on quality measures. An ACDIS survey revealed the extent of the knowledge gap. It also revealed that many were unaware of regulations associated with determining admit type. Admit type is defined by the National Uniform Billing Committee (NUBC). This project has become a huge initiative for Penny and UC Davis. Penny is working with a government agencies to ensure parity among hospitals.  These efforts prove what I have known all along, CDI professionals are problem solvers. No wonder we keep getting more and more added to our plates!  

Balancing Innovation with Insights: Why Technology Alone Isn’t Enough in CDI

Artificial Intelligence (AI) was everywhere at the conference, from exhibitor booths to breakout presentations on optimizing CDI workflows. As staffing challenges persist across the industry, technology is rapidly advancing to fill gaps in efficiency and capacity. Many larger CDI teams now include dedicated educators and data analysts, and we may soon see informatics professionals formally integrated into CDI structures. It’s encouraging to see CDI becoming so profoundly connected to the revenue cycle, with more tools than ever to support accuracy and impact. 

But as we accelerate toward automation, we must not lose sight of the human element. Critical thinking, professional judgment, and experience remain at the core of compliant, adequate documentation. Technology is only as powerful as the people who use it. That’s why forums for professional growth are so vital, especially for those newer to CDI or working remotely at smaller hospitals. Many of us learned this work through in-person collaboration and hallway conversations. We owe it to the next generation to create space for that kind of mentorship, even in virtual settings. I’m so lucky that Brundage Groups allows me to support our profession.  

For expert perspectives on clinical documentation, denials management, and revenue cycle performance, subscribe to Revenue Cycle Insights—our monthly newsletter for healthcare leaders.

The post The Evolution of CDI: Lessons Learned from ACDIS 2025 appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

For years, Physician Advisors were considered adjacent to hospital leadership — valuable but not essential for decision-makers focused on revenue cycle performance. Most operational decisions flowed through the director of case management or utilization management, who reported to finance leaders, not the CMO. Physicians, meanwhile, were expected to stay in their lane: care delivery.

But today? The landscape looks very different.

The shift was undeniable at the recent National Physician Advisors Conference (NPAC). “It was so obvious,” said Tim Brundage, MD, CEO of Brundage Group. “The physician minds were directly connected to the revenue minds. Doctors had a direct line to the hospital’s revenue power plant.”

Physician Advisors are increasingly becoming key influencers in the healthcare business. They report to CFOs, help shape utilization strategies and are called on to bridge the gap between documentation, compliance, and financial performance. This isn’t a subtle change; it’s an organizational power shift.

“We used to attend conferences like NPAC with the sense that there weren’t decision-makers there,” Dr. Brundage recalled. “Physicians were in the service industry, and the business of healthcare was happening around them, not through them. That’s no longer the case.”

A New Generation of Business-Minded Physicians

Today’s Physician Advisors are embracing the economics of healthcare. They’re earning MBAs to run hospital systems. They’re learning from business schools, not just medical journals. And they’re becoming vital to organizations that want to succeed in a system defined by complexity and cost.

Why External Partners Matter

While internal Physician Advisor programs are gaining traction, most hospitals’ internal PA programs aren’t mature yet.  Many still run with fractional FTEs — 0.2 or 0.3 FTE Physician Advisors spread across five or six individuals who are still managing clinical duties. That’s enough to contribute but not enough to lead consistently.

Internal teams are pulled in multiple directions, rounding one minute and answering UM questions the next. Their focus is fragmented, and incentives prioritize clinical flow over financial accuracy.

Brundage Group offers a more strategic approach.

Our Physician Advisors are singularly focused on outcomes. With thousands of case reviews and proprietary analytics, they drive faster escalations, stronger documentation, and measurable revenue gains. We don’t just fill gaps, we strengthen programs, support internal teams, and help hospitals lead confidently.

“We support hospitals through the build-out phase,” said Dr. Brundage, “but also long after. Whether it’s supporting the internal team or handling transactional reviews, we’re there to help them succeed.”

The post The Strategic Ascent of Physician Advisors in Healthcare appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Industry experts agree that combining artificial intelligence (AI) and automation will transform revenue cycle operations. A recent McKinsey report highlights that healthcare organizations leveraging AI to streamline their revenue cycle are better positioned to improve margins, reduce administrative burden, and support clinical teams more effectively. At Brundage Group, our tech-enabled Physician Advisory solutions echo this call to action—bringing practical AI to the forefront of utilization management while keeping clinical expertise at the core.

Introducing Brundage Group Intelligence

Brundage Group Intelligence is the engine behind our purpose-built utilization management and revenue cycle analytics solutions, aligning the right staff with the right patients at the right time to optimize status, streamline decisions, and secured earned revenue for care provided.

By combining proprietary analytics, smart workflows, and industry-defining Physician Advisors who drive revenue and compliance outcomes, we help hospitals:

• Capture earned revenue
• Strengthen compliance
• Optimize clinical workflows
• Improve visibility across UM processes

This holistic approach bridges the gap between strategy and day-to-day operations, enabling teams to operate more effectively and efficiently and generating stronger financial outcomes.

Technology Backed by Clinical Insight

Brundage Group doesn’t replace clinical expertise with AI or automation. Instead, our technology supports smarter, faster decisions that improve compliance and global net revenue.

Every solution we build is supported by:

• Proprietary analytics tailored to the UM/Physician Advisor workflow
• Seasoned Physician Advisors validating and guiding insights
• Transparent dashboards for cross-functional alignment
• Real-time data for more intelligent prioritization and compliance
• Committed to cost containment and revenue recovery by closing the gap between internal capacity and/or performance gaps, and full earned revenue capture

This model empowers teams to focus on the right patients and cases, support appropriate patient status assignments, and capture earned revenue for care provided.

Delivering Smarter Workflows and Stronger Outcomes

With Brundage Group Intelligence, hospitals get more than tools; they get a better way to manage utilization and Physician Advisory operations. The result? Improved clarity, streamlined operations, and positive net revenue impact.

In our upcoming blog series, we’ll discuss the four types of AI: narrow (Rules-Based) AI, Machine Learning (ML), Generative AI, and Agentive AI, and how each is deployed within Brundage Intelligence to drive smarter workflows, reduce administrative burden, and improve revenue capture.

We’ll also examine the challenges of AI when humans are removed from the equation and whyclinical oversight, context, and judgment are criticalin the age of automation.

The post Revenue Integrity Through Tech-Enabled Solutions appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

This recognition is more meaningful because the results are based on employee surveys. 

There is no greater honor than knowing that our people, the heart of Brundage Group, feel supported, valued, and connected in our work. 

At Brundage Group, we know that building an exceptional workplace doesn’t happen by accident. It’s intentionally shaped daily by living out our Core Values: 

Accountability, Collaboration, Community, Excellence, Innovation, Integrity, Professional Courage, and Respect.

As our Chief Culture Officer shared so perfectly: 

This award belongs to every member of our team. 

Brundage Group has been ranked among the Best Places to Work by the Tampa Bay Business Journal for three years in a row — and it’s all because of you. 

Here’s to many more years of success together with the collaboration of our employees, clients and partners.

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Hospitals face increasing pressure to avoid denials as payers intensify their scrutiny of inpatient status determinations. This often causes a shift toward assigning more cases to observation status, even when inpatient may be clinically appropriate.

Why does this happen? When hospitals experience frequent denials, physicians and utilization management teams naturally adjust their approach, particularly in cases that fall in the “gray area” between observation and inpatient status. Over time, this creates a reactive cycle where payers effectively train hospitals to prioritize minimizing denials over making accurate status determinations based on medical necessity.

Don’t allow payer tactics to dictate patient status determinations at your hospital!

While some denials are preventable hospitals must evaluate whether the focus on denial prevention is inadvertently discouraging appropriate inpatient admissions. Data-driven strategies, combined with physician education and real-time documentation improvement, can mitigate unnecessary denials when patients are placed in the appropriate status (inpatient, observation, etc.).

What is the Link Between Increased Denials and Overall Net Collected Revenue?

Denied claims don’t just impact the bottom line—they also increase administrative burden and delay reimbursement. Hospitals must allocate already limited resources to keep pace with appeals and resubmissions as they battle payer denials. Resulting in:

• Increased labor costs
• Higher volumes of peer-to-peer reviews and written appeals
• Financial strain due to revenue loss from delayed and underpayments

But what if hospitals viewed denials differently? A higher volume of denials can indicate that a hospital is actively pushing back on payers and not leaving revenue on the table. A low denial rate may seem like a win, but it could signal missed opportunities for appropriate reimbursement. Hospitals that effectively challenge payers may see more denials upfront; however, they also stand to gain a significant increase in revenue.

Denials create financial strain due to revenue loss from delayed and under payments. The challenge lies in balancing compliance regulations with financial sustainability, ensuring that hospitals are not leaving revenue on the table while adhering to payer guidelines- which are not always compliant. Brundage Group’s success comes from understanding the rules and regulations, allowing us to challenge non-compliant or unnecessary friction in payer processes and policies.

Are Hospitals Inadvertently Prioritizing Cost Containment at the Expense of Long-Term Financial Health?

Cost containment is a priority for hospitals, but it can have unintended consequences when attempted in a silo. Efforts to reduce costs in inpatient admissions, length of stay, and utilization review can lead to short-term savings but risk significant long-term revenue loss. If fully complaint revenue goes uncaptured, the savings may be negligible in comparison. For example, the cost of escalating a case for Physician Advisor review is minimal compared to the financial benefits of converting a case from observation to inpatient.

Hospitals must consider the true cost of Physician Advisor support, denial support services, and cost containment strategies.

• Physician Advisor Support Costs: Engaging Physician Advisors helps ensure appropriate patient status determinations and prevent unnecessary denials. Some hospitals may struggle to justify the investment without understanding the return on investment (ROI) provided by external Physician Advisor support.
• Denial Support Costs: Hospitals without internal expertise may outsource denial management.  Although this can add to overall expense, the incremental revenue often offsets the increased expense and leads to an increase in net revenue.
• Risk of Narrow Focus on Denial Rates: When teams focus solely on denial rates, they lose sight of the broader revenue cycle, leading to unintended financial consequences. A narrow focus on denial rates can overlook the downstream financial impact on reimbursements, penalties, and overall revenue performance.

How Can Hospitals Balance Compliance and Revenue Optimization Without Compromising Quality Care?

Finding the balance between compliance and revenue optimization is critical for sustainable hospital operations.

1. Enhancing physician documentation at the point of care can prevent inappropriate denials and reduce administrative burdens.
2. Strategically leveraging Physician Advisors and Utilization Review teams helps support accurate patient status assignments and mitigate payer disputes.
3. Revenue cycle analytics identify denials and admissions patterns allowing hospitals to adjust their strategies in real-time.
4.  Investing in education, process improvement, and technology solutions helps reduce denial rates while maintaining compliance.
5. Establishing alignment across clinical, compliance, and finance departments to optimize patient care and financial outcomes.

Hospitals that take an assertive approach to revenue integrity and quality care are better positioned to navigate financial challenges. By addressing rising denial rates and inpatient status scrutiny, hospitals can minimize disruptions to patient care and operational efficiency.

Implementing comprehensive strategies prioritizing patient care while ensuring compliance allows hospitals to mitigate financial risk, optimize reimbursement, and maintain long-term stability.

Take Back Control of Your Revenue

Don’t let payer denials train your team into playing small.

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