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.

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.

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.

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.

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.

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

Tampa, Fla. – [September 23, 2025] 

The Patient Protection and Affordable Care Act (ACA) of 2010 was designed to reduce the number of uninsured by providing a continuum of affordable coverage options. The ACA increased the volume of low-income adults who qualify for Medicaid coverage beyond those with disabilities through Medicaid expansion to those with incomes 138% of the federal poverty level.  

KFF reports that in 2024, 44 million (16.4%) of the nonelderly U.S. population participated in an ACA program (marketplace, Medicaid expansion or a Basic Health Plan). Enrollment in marketplace plans reached a record high of 21.4 million. Enhanced premiums lower payments for health insurance policies. Some policies are free for those with incomes up to 150% of the federal poverty level.  

Enhanced premium tax credits expire in 2025. If these subsidies are not extended it will increase the volume of uninsured patients beyond projected losses due to changes in Medicaid eligibility.  

• Without the tax credit, healthy people will likely decline health insurance, increasing the uninsured population by an average of 3.8 million annually.  

• Premiums will increase by more than 75% on average for those who remain within the health insurance marketplace, which will contribute to higher levels of bad debt for most hospitals.  

It is estimated that these tax credits allowed 10 million people to gain affordable healthcare coverage through the health insurance marketplace. The American Hospital Association (AHIA) Fact Sheet on Enhanced Premium Tax Credits cite the impacts of these lost subsidies include:  

• An average increase of at least $700 in the price of marketplace health insurance plans.  

• 4.2 million mostly rural and low-income people becoming uninsured by 2034.  

• A reduction in hospital spending of $28 billion over 10 years creating “considerable financial stress on hospitals, health systems and other providers, which will face more uncompensated care and bad debt.”  

What This Means For You: 

The expiration of premium tax credits has the potential to reverse years of progress in reducing the uninsured population, with far-reaching consequences for patients, hospitals, and communities. The financial impact – more uncompensated care, greater bad debt, and reduced hospital resources – will directly affect care delivery, especially in rural and underserved areas.  

Now is the time for healthcare leaders to raise awareness and advocate for policies that preserve access to affordable coverage. Brundage Group encourages Physician Advisors, hospital executives, and clinical leaders to engage in this dialogue to ensure your organization’s voice is heard on an issue that directly impacts patient care and financial sustainability.  

The post The Patient Protection and Affordable Care Act’s Premium Tax Credits  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.

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.

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.

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.

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.

The post Denials vs. Inpatient Admission Percentage – Examining the Financial and Clinical Impact appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Now that we’ve got your attention. 

Hospitals are complex ecosystems where clinical care, compliance, and financial leaders must work together. Yet, many times, these departments inadvertently operate in silos, prioritizing their department metrics at the expense of overall hospital performance.  

The Three-Legged Stool: A Balanced Approach 

Patient care, compliance, and financial health must be balanced- like a three-legged stool supporting a hospital’s success. When these priorities fall out of alignment, the entire hospital feels the impact.  

High-performing organizations don’t manage problems in silos- they take a strategic approach to optimize their teams, keeping experts focused and aligned.  

Long-term sustainability hinges on maintaining balance across these three areas: 

• Clinical Care delivers quality patient care while maintaining efficiency. As healthcare shifts toward value-based care models, maintaining compliance is essential. 
• Compliance adheres to regulations, mitigating risks that could lead to penalties. Effective regulatory compliance strategies ensure organizations remain legally and ethically sound. 
• Finance works to optimize revenue diversification through service line expansion in addition to optimizing revenue capture, assuring the hospital remains financially viable. 

Are your processes, policies, and plans working together, or are they fighting against each other?  

Experts must have deep knowledge in their respective areas, but when they operate in isolation, they risk missing the broader impact of their decisions. When each leader focuses solely on their domain without considering hospital-wide goals, misalignment occurs. Success comes from keeping experts aligned within a cohesive strategy that balances patient care, compliance, and financial sustainability. 

The Cost of Misalignment 

Optimizing one department at the expense of another can have unintended consequences. If compliance policies restrict care pathways too aggressively, clinical teams may struggle to provide necessary services. If financial measures push for maximum revenue without regard for compliance and patient care, the hospital risks audits and penalties. If patient care decisions are made without financial consideration, the hospital may be unable to sustain operations. 

Measuring What Matters 

To maintain balanced, hospitals must track key performance indicators (KPIs) that reflect the broader ecosystem rather than just isolated departmental goals. These common KPIs, when measured in a silo, can unintentionally harm your hospital:  

• Clinical Care: OBS/INPT %, readmission rates, case mix index (CMI) 
• Compliance: Medicare self-denial rate, clean claim rate, % of code 44 cases 
• Finance: Net revenue per patient day, denial overturn rates, cost per case 

If you are using these common KPIs without understanding the impact to global throughput, you are likely damaging your hospital’s financial health.  

What If Leaders Switched Roles? 

Imagine if your Chief Compliance Officer (CCO), Chief Medical Officer (CMO), and Chief Finance Officer (CFO) rotated roles. How would their priorities shift? Would the CMO recognize the financial constraints of care delivery? Would the CFO gain a new appreciation for clinical decision-making? Would the CCO better understand the operational challenges associated with maintaining compliance? 

True success requires a hospital-wide perspective, where leadership aligns mission, measures, and motivations at every level. Breaking down silos and fostering collaboration ensures   appropriate standard of care, maintains compliance, and maximizes net revenue- sustaining viability, funding  essential personnel and programs, and enhancing both patient outcomes and staff quality of life. 

The post The Bigger Picture: Aligning Patient Care, Compliance, and Financial Health appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Why Peer-to-Peer Reviews Matter 

Medical necessity denials are a common challenge for hospitals, often resulting in lost revenue and increased administrative burdens. The peer-to-peer review process provides an opportunity to challenge these denials by engaging directly with payer medical directors. When executed effectively, a robust peer-to-peer process mitigates payer denials and protects earned revenue.  

Understanding the Peer-to-Peer Process 

Overcoming Common Challenges 

Hospital-based physicians often face difficulties when tasked with engaging in peer-to-peer discussions. These challenges include: 

• Time Constraints: Balancing patient care responsibilities with the demands of appeal processes can strain resources. 
• Limited Experience with Payers: Physicians often lack familiarity with payer medical directors’ tactics and arguments. 
• Emotional Stress: Advocating for medical necessity in a high-pressure conversation can be daunting for those unaccustomed to the process. 

Hospitals can address these obstacles by equipping their teams with the necessary training, resources, and support to confidently navigate the peer-to-peer process  

Key Metrics to Evaluate Success 

Three metrics are critical in assessing the effectiveness of peer-to-peer strategies: 

• Pursuit Rate: This refers to the frequency with which hospitals pursue peer-to-peer calls for denied inpatient status. High pursuit rates demonstrate a proactive approach to denial management. 
• Overturn Rate: This represents the percentage of denials successfully overturned when a peer-to-peer is performed.  A strong overturn rate reflects the effectiveness of the argumentation and advocacy employed. 
• Effective Overturn Rate: This represents the overturn rate for peer-to-peers when all opportunities are considered.  

Optimizing Net Revenue Impact: The Pursuit-Overturn Matrix 

Pursuit rate and overturn rate metrics should be evaluated to ensure that hospitals optimize for maximum net revenue impact rather than just a high overturn rate. A higher pursuit rate, even with a slightly lower overturn rate, can lead to greater overturned cases, which has a stronger positive financial impact. 

For example:

In the first scenario, the overturn rate appears stronger (80% vs. 60%), but the second scenario results in six more overturned cases, which—assuming a payment difference of $5,000 per case—translates to $30,000 more in recovered revenue. This demonstrates why optimizing for the highest positive net revenue impact, rather than just a high overturn rate, is critical. 

Enhancing Your Peer-to-Peer Strategy 

An effective peer-to-peer approach involves engaging in the process to master it. Hospitals can improve their strategies by: 

1. Building Expertise: Training staff on payer guidelines and common denial tactics. Partnering with organizations like Brundage Group can provide access to seasoned Physician Advisors with deep experience in payer interactions and appeals. 
2. Focusing on Collaboration: Encouraging a team-based approach to appeal processes and leveraging external support to alleviate administrative burdens. 
3. Leveraging Technology: Using data analytics to track trends, identify denial patterns, and optimize processes. Brundage Group’s comprehensive data tracking keeps hospitals informed about outcomes and helps identify areas for sustainable improvement. 

By incorporating these strategies and collaborating with experts such as the Physician Advisors at Brundage Group, hospitals can build a more robust, proactive denial management program that improves success rates and enables the hospital-based physicians to focus on patient care. 

How Brundage Group Can Help

Brundage Group specializes in managing the peer-to-peer process from start to finish. Our seasoned Physician Advisors bring extensive experience and collegial relationships with payer medical directors, supporting a strong advocacy approach. 

We offer: 

• Comprehensive scheduling and facilitation. 
• Data tracking to hold payers accountable and to identify denial trends. 
• Expertly drafted written appeals for cases that require additional support. 

With a 93%+ pursuit rate and a 65%+ overturn rate, our proven compliant methods help hospitals recover denied revenue while reducing administrative burdens. 

The post Peer-to-Peer Reviews for Medical Necessity Appeals: Key Strategies for Revenue Recovery appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

As healthcare systems navigate an increasingly complex environment, hospitals must have robust strategies to secure earned revenue, support compliance, and streamline operations. Physician Advisors serve as the payer watchdogs, providing hospitals with the expertise and oversight necessary to thrive in today’s demanding landscape.

Physician Advisors help address these critical areas that contribute to hospitals’ financial health:

• Revenue Protection: Physician Advisors proactively address potential denials by understanding payer requirements and validating appropriate reimbursement for services rendered.
• Compliance Oversight: Physician Advisors support accurate status assignment and coach hospital-based providers about medical necessity documentation, helping hospitals meet regulatory standards and capture reimbursements for the quality care delivered.
• Operational Efficiency: Physician Advisors provide expert guidance to ensure patient care is delivered in a setting that is appropriate for the patient while securing clinical documentation that aligns with payer requirements.

The term “watchdog” demonstrates the vigilance and dedication that Physician Advisors bring to their work. They are active, engaged, and committed to protecting hospital viability by fostering alignment across departments to support revenue capture.

At Brundage Group, we support hospitals with our experienced Physician Advisors who bring this critical oversight to life. Our mission is to partner with hospital systems to ensure they capture earned reimbursements for the high-quality care delivered, remain compliant, and stay operationally efficient— all essential for effectively serving their communities.

If your hospital system is ready to compliantly strengthen its revenue strategies, consider the value of Physician Advisors as your payer watchdog.

Let us help you navigate today’s clinical revenue challenges with confidence.

The post Physician Advisors: Protecting Hospital Viability appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Departments Benefiting from Physician Advisor Support

Physician Advisors bring immense value to several key hospital departments, including:

• Utilization Review: Confirming medical necessity for observation and inpatient admissions and hospital services assuring the patient is in the correct status at the right time.
• Clinical Documentation Integrity (CDI): Enhancing documentation accuracy to reflect patient acuity and resource utilization in terms that can be captured by the ICD-10 code set.
• Case Management: Supporting effective discharge planning and length-of-stay management for both observation status and admitted patients.
• Quality Management: Improving performance of publicly reported quality-of-care measures.
• Hospital Coding and Billing: Addressing documentation gaps that impact coding accuracy.
• Denials Management: Assisting in appealing and overturning unjustified denials and preventing future occurrences.
• Leadership Alignment: Engage with senior leaders of the facility to align goals, supporting the organization to maintain long-term viability and operational success.

Key Functions of a Physician Advisor

Physician Advisors perform a variety of roles, including:

• Patient Status Support: Applying physician judgment to cases where screening criteria does not support the ordered patient status.
• Observation Length of Stay Management: Identifying observation status patients who meet medical necessity for an upgrade to inpatient status.
• Utilization Review Denial Management: Engaging with payers in peer-to-peer discussions for inpatient authorizations, preventing unnecessary Medicare patient status downgrades, and appealing medical necessity denials.
• Clinical Validation: Verifying documented diagnoses at high-risk for denial and appealing diagnoses removed by payers for a lack of clinical evidence e in the health record.
• Length of Stay Management: Collaborating with case management teams to optimize patient flow.
• Education and Advocacy: Providing guidance to clinical teams about how their documentation and orders impact hospital reimbursement.

Why Full-Time Physician Advisor Support Is Essential

Healthcare systems are increasingly recognizing the value of full-time Physician Advisor support for their ability to:

• Defend Hospitals Against Payers: It’s often an uneven battle when bedside providers are asked to argue against experienced payer medical directors. Physician Advisors bring the expertise to level up the playing field.
• Mitigate Revenue Leakage: Addressing potential claim issues as front-end revenue cycle processes can promote revenue cycle efficiency and decrease administrative costs.
• Provide Clinical and Provider Perspectives: They provide clinical revenue cycle teams with timely, informed input without pulling bedside providers away from patient care.
• Enhance Physician Satisfaction: By handling peer-to-peer appeals and denials, Physician Advisors allow clinicians to focus on their primary responsibility—patient care.

Why A Strong Physician Advisor Program Matters

A successful Physician Advisor program is built on meaningful metrics, relevant education, and collaboration. Physician Advisors become essential partners in improving hospital operations, publicly reported quality metrics, and financial outcomes by addressing specific challenges and providing tailored solutions. Their expertise allows healthcare systems to navigate complexities, reduce denials, and capture earned revenue for the quality of care delivered.

The post The Vital Role of a Physician Advisor in Modern Healthcare appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

However, the effectiveness of a Physician Advisor depends on proper training and expertise. This role requires an in-depth understanding of medical necessity criteria, reimbursement systems, payer tactics, and clinical documentation improvement (CDI). With the proper training and support, hospitals can efficiently utilize this vital resource and gain opportunities to improve outcomes and financial health.

Investing in well-trained Physician Advisor support will positively transform your revenue cycle and operational efficiency, delivering significant economic returns.

• Specialized expertise: External Physician Advisors bring deep experience across diverse healthcare systems and offer best practices tailored to your hospital’s needs.
• Data-driven insights: Vendors leverage analytics to identify trends, optimize workflows, and maximize ROI in status determinations, denial prevention, and compliance.
• Avoid Physician burnout: With staffing shortages and growing demands, external Physician Advisor support ensures your clinical team stays focused on patient care without added administrative burdens.
• Optimized economics: External programs provide prompt ROI by streamlining operations and unlocking millions in revenue potential without the overhead of building an internal program.
• Power of network: External Physician Advisors bring the collective expertise of working across hundreds of hospitals, enabling them to navigate payer relationships, resolve disputes efficiently, and implement proven best practices to optimize compliance, workflows, and revenue cycle performance.

Is an Internal Program Worth It?

Internal Physician Advisor programs can provide unique advantages, such as fostering strong relationships with medical staff and offering leadership opportunities that physicians may seek. An in-house Physician Advisor creates a visible presence within the hospital, promoting buy-in from medical teams.

However, the economics of internalizing a Physician Advisor program often presents significant challenges. Establishing and maintaining an internal team requires considerable recruitment, onboarding, and ongoing training investment. Physicians stepping into this role need extensive education in CDI, medical necessity criteria, payer policies, and revenue cycle processes—training that takes time and resources to deliver effectively.

Furthermore, staffing shortages and increasing clinical demands can make allocating physicians for non-clinical administrative roles challenging without straining existing teams. Hospitals must also account for ongoing administrative overhead, including compensation, benefits, and program management.

The Case for External Physician Advisor Support

In contrast, external Physician Advisor support eliminates these barriers. Vendors offer ready access to highly trained experts who bring both clinical and operational expertise and advanced data analytics to optimize decision-making. This scalable solution provides hospitals with prompt ROI while mitigating the risks and hidden costs of building an internal program from scratch.

For many, leveraging external expertise strikes the ideal balance between performance, flexibility, and cost-effectiveness. Ready

The post The Physician Advisor: The Administrative Role Hospitals Can’t Afford to Overlook appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The Centers for Medicare & Medicaid Services (CMS) recently implemented Rule 4204F to address a significant gap in Medicare beneficiary rights following a pivotal legal case, Alexander v. Azar. This ruling recognized the need for due process when a patient’s hospital classification changes from inpatient to outpatient, commonly called a “Code 44”. This article provides an overview of the rule, the associated rights and processes, and its implications for patients and hospitals.

The Centers for Medicare & Medicaid Services (CMS) recently implemented Rule 4204F to address a significant gap in Medicare beneficiary rights following a pivotal legal case, Alexander v. Azar. This ruling recognized the need for due process when a patient’s hospital classification changes from inpatient to outpatient, commonly called a “Code 44”. This article provides an overview of the rule, the associated rights and processes, and its implications for patients and hospitals.

Background on Rule 4204F

The Alexander v. Azar case highlighted the inherent unfairness in denying patients the ability to appeal their reclassification from inpatient to outpatient status. This change often has financial implications, particularly for those without Medicare Part B coverage. While the court ruled that beneficiaries are not entitled to appeal rights, the court also directed HHS to establish an appeals process, culminating in Rule 4204F. The new appeal process allows Medicare beneficiaries with a tangible or financial interest to contest their reclassification through the mechanisms outlined in 42 CFR Part 405, Subpart I, and Subpart J.

Eligibility for Appeals

When a beneficiary disagrees with the hospital’s decision to reclassify their status while still in the hospital, they can appeal this decision with the BFCC-QIO. To qualify for an appeal under Rule 4204F, beneficiaries must meet specific criteria:

1. They were formally admitted as an inpatient but later reclassified as an outpatient receiving observation services under Code 44.

And

2. They lack Medicare Part B coverage.

Or

3. They remain hospitalized as outpatients receiving observation services for at least three days after the original inpatient order, but the inpatient portion is fewer than three days (e.g., the beneficiary would have qualified for SNF payment under Part A except for the Code 44).

This process applies exclusively to beneficiaries with Original Medicare. Per the 4204F, those enrolled in Medicare Advantage plans are already covered under a separate, more robust appeal framework as outlined in 42 CFR §422.562(b)(4).

Appeal Processes: Retrospective vs. Concurrent

There are two types of appeals:

1. Retrospective Appeals: These apply to hospital stays dating back to January 1, 2009, and must be filed with the Medicare Administrative Contractor (MAC). While less relevant to ongoing hospital operations, overturned appeals require hospitals to reprocess the cases correctly.
2. Concurrent Appeals: These are filed during the patient’s stay and focus on the immediate implications of the Code 44 reclassification. They must be submitted to the Quality Improvement Organization (QIO) before the patient is discharged, and the QIO is obligated to render a decision within one calendar day after receiving all pertinent documentation. These appeals can also be classified as “expedited” or “standard.”

Critical Compliance Requirements

Hospitals must adhere to several requirements to ensure compliance with Rule 4204F:

• Medicare Covered Services Notice (MCSN): This newly mandated notice is critical to the appeal process. It must be delivered to eligible beneficiaries as soon as they meet the criteria to file an appeal. The MCSN:
  • Should not be conflated with other required notifications like the Medicare Outpatient Observation Notice (MOON) or the initial Code 44 notification.
  • Must be delivered in cases where observation services extend beyond three days, or when patients’ overall stay qualifies them for Skilled Nursing Facility (SNF) benefits.
  • Should be signed by the patient or noted as refused, with records retained by the hospital.

Failure to deliver the MCSN accurately and timely could result in noncompliance, undermining the appeal rights of eligible beneficiaries.

Key Considerations for Hospitals

While CMS estimates the volume of these appeals to be relatively low—around 15,000 nationwide, or fewer than three per hospital annually—the operational implications for hospitals are noteworthy. Facilities should:

1. Develop robust workflows for identifying eligible patients and delivering the MCSN promptly.
2. Ensure all documentation, including the patient’s refusal to sign, is appropriately recorded and retained.
3. Maintain compliance with the expedited timelines for submission of documentation to the QIO during concurrent appeals.

Financial and Operational Implications

A critical distinction of the appeal process is that it does not afford beneficiaries financial liability protections akin to those provided during discharge appeals. However, hospitals can only bill patients after the QIO renders its decision. This places additional pressure on facilities to handle these cases efficiently while safeguarding patients’ rights.

Closing

CMS Rule 4204F represents a significant step in addressing due process for Medicare beneficiaries affected by inpatient-to-outpatient reclassification. While the overall volume of appeals is expected to be low, hospitals must remain vigilant in implementing the associated processes, ensuring compliance with notice delivery, and respecting the rights of eligible patients. By doing so, healthcare providers can navigate the complexities of Code 44 reclassifications while maintaining trust and transparency in patient care. Per an email from Acentra, a large QIO covering several regions, the rule will be implemented on February 14, 2025. We suspect this will be the same nationwide, but advise hospitals check with their specific QIO. The MCSN form can be found here.

The post Understanding Beneficiary Appeal Rights After Inpatient-to-Outpatient Status Changes appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

By Ben Kartchner, MD

Dr. Ben Kartchner is Associate Chief Medical Officer and Executive Physician Advisor at Brundage Group. He has worked as a Physician Advisor for almost a decade and previously served in the roles of associate medical director of care management and medical director of utilization management at various health systems. 

A few weeks ago, during the weekly Monitor Monday broadcast, healthcare attorney David Glaser presented a great segment that simplified the two-midnight rule into two essential parts: first, that a patient must require hospital care, and second, that the need for that care must be expected to span two midnights.

Yet despite the clarity of these conditions, why does conflict persist between payers and hospitals on how this rule is applied?

One main issue is that some payers still need to fully recognize the rule despite clear regulations. However, a more significant challenge stems from differences in defining and understanding what constitutes hospital care.

This leads to an important question: What exactly is hospital care? Is it simply any skilled service provided within the hospital walls? Alternatively, is it a restrictive definition used by many Medicare Advantage companies, where a patient must meet strict third-party criteria to qualify?

What does it mean for a patient to require hospital care? For insight, we look at Rule 1599F—the two-midnight rule—which clarifies that “The crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk or discharge the beneficiary because they may be safely treated through intermittent outpatient visits or some other care.“

If the required care could be delivered safely outside the hospital or in a less intensive setting, it should not count toward the two-midnight benchmark. Notably, the decision should be evidence-based rather than it be convenient for the patient or physician, and external, third-party criteria should not dictate it.

In my most recent segment during the Monitor Monday broadcast, I discussed how an order for observation services indicates that the physician cannot confidently predict a patient will need hospital care for over two midnights. Per the guidance above, on day two of the hospital stay, the patient must be discharged, or documentation to substantiate the need for ongoing hospital care must be present.

Based on the above guidance from the two-midnight rule, this documentation should expressly state or make obvious why the same care cannot safely be provided elsewhere or through periodic outpatient visits. Unfortunately, in our busy healthcare environment, physicians often rely on templated language that needs more specifics on patient acuity or the unique need for ongoing hospital care.

For example, I was able to overturn a denial on peer-to-peer review for a patient with chronic obstructive pulmonary disease (COPD) on room air when the physician documented persistent shortness of breath, tachypnea, and the need for IV steroids. However, despite similar presentations, a patient whose chart stated they had “improved since admission” and whose exam appeared as a generic template was denied because the documentation did not support the need for hospital care.

Both required hospital care, but only one was paid as an inpatient.

How can we close this documentation gap?

At my previous organization, we piloted an initiative to address documentation gaps. Adding a dedicated section to the physician’s note template prompted hospitalists to include one concise statement, based on their medical judgment, explaining why the patient required hospital care and could not be discharged. The documentation was to be based solely on the medical rationale and proposed or required treatment and not consider social or other discharge barriers outside the physician’s control.

We wanted them to tell us when the patient was medically cleared and, if not medically cleared, why not. As you can imagine, implementing this required substantial engagement and education and did not happen overnight. Physicians struggled to distill this information into a statement other non-physicians can understand. They are taught to list diagnoses and the appropriate treatment for that diagnosis.

No text or handbook provided in residency teaches young physicians when patients should be discharged. These practice patterns are institutional and passed down from attendings to residents.

However, in implementing this process, I found that many young hospitalists assumed that someone had determined they needed to be in the hospital because the patient was there. Many didn’t even realize people were looking to them to help with these decisions. I won’t lie; getting this to change takes some heavy lifting, but it ultimately streamlined the status process, reduced denials, and increased overturn rates during peer-to-peer reviews. It also improved communication and participation in multidisciplinary rounds, which helped the care management team organize discharge plans for skilled nursing facilities, home health, and other services.

Instead of the discharge process being worked “in series,” where the care management team would have to wait until the physician cleared the patient to start working on placement, our goal was to have parallel processes that lined up at the same time, thus reducing unnecessary delays waiting for acceptance, authorization, supplies, etc. This proactive coordination significantly decreased avoidable hospital days and length of stay, benefiting both patients and the hospital.

In sum, the two-midnight rule is evident in its intent, but clarity in documentation supporting the ongoing need for hospital care is the third essential step in reducing denials and preventing audit takebacks.  Collaboration between the Physician Advisor and hospitalist medical director is required to provide physician education and promote engagement and buy-in.

However, the reality is we overcomplicate the two-midnight rule. The rule is clear. It’s often the documentation and rationale that is missing. If you can get that part in order, it is as easy as one, two, three.

The post Two-Midnight Rule: Greater Understanding Yields Better Results appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Unlocking Compliance, Continuity, and Revenue Potential with Certus Radar™ appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Brundage Group’s Success in Overturning Patient Status Denials from Kodiak’s Medicare Advantage Study appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Recognizing the Role of Physician Advisors in Case Management appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Thinking of Transitioning to an Internal Physician Advisor Program? appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Mid-Revenue Cycle Optimization: How Brundage Group Helps Hospitals Secure Earned Revenue appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Why Providers Should be Documenting “Evidence of” a Diagnosis Based on Clinical Findings appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Optimizing Coordination Among Mid-Revenue Cycle Stakeholders appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Is Everything in the Medical Record “Documentation”? appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Is There a Blind Spot in Your Mid-Revenue Cycle? appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Healthcare-Associated Pneumonia: Why You Should Not Diagnose It appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Know the New Pediatric Sepsis Criteria appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Optum (UHC) Profits from Denying ED Payments appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Take control of Medicare Advantage denial challenges appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Guest Blog: A Rebeginner’s Guide to Peer-to-Peer Appeals appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Physician Advisor Perspective to Avoid a Potential DRG Clinical Validation Downgrade Denial of DRG 853 appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Expand the role of the physician advisor to break down silos appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

The post Is your hospital slipping on industry rankings? appeared first on Physician-Led Advisory & Revenue Cycle Analytics.