Today, as Lead Clinical Coding Analyst at Brundage Group, Robin helps healthcare organizations strengthen DRG accuracy and reduce denial risk before claims are submitted. But her understanding of denial management and DRG integrity was built through a path that was anything but linear.

In fact, much of her expertise was built by working on the opposite side of the table.

From Physician Billing to Revenue Integrity

Robin’s healthcare career began in the late 1990s, providing medical billing services for physician practices while raising her children at home.

“I wanted to have my own business so I could be home with my kids,” she recalled. “This was during the dial-up internet era, so everything took a little longer, but it gave me exposure to a wide variety of specialties and how reimbursement worked.”

As payer requirements became increasingly complex, Robin found herself drawn to the broader challenges of healthcare reimbursement and documentation. After earning inpatient coding credentials, she transitioned into the hospital space and eventually discovered a passion for DRG auditing.

“I thought I was going to love coding,” she said. “What I realized was that I enjoyed auditing much more. I liked identifying problems, finding opportunities, and understanding why things happened.”

That curiosity ultimately led her into the payer world, where she spent years conducting DRG audits, developing recovery concepts, and reviewing provider appeals for some of the nation’s largest health plans.

Learning the Payer Playbook

Robin’s experience reviewing claims and appeals on behalf of payers gave her an uncommon advantage: she learned exactly what auditors look for when evaluating documentation, coding accuracy, and clinical support.

“I was reading the appeal letters hospitals submitted and deciding whether I agreed with them or not,” she explained. “That experience taught me what the auditor on the other side wants to see.”

Over time, Robin became known for her deep understanding of payer tactics and denial trends. Her unique perspective earned her the nickname “Queen of Denial,” which eventually inspired her to develop a denial analytics application.

The tool helped organizations identify denial patterns, track root causes, and uncover documentation gaps that contributed to reimbursement challenges.

“It allowed us to drill down into why denials were happening,” Robin said. “Instead of just looking at the denial itself, we could identify documentation issues, education opportunities, and patterns that needed attention.”

While technology has evolved significantly since then, the experience reinforced something Robin continues to believe today: understanding denial risk requires more than simply reacting to denials after they occur.

Moving from the Payer to Provider Side

After years of working for payers, Robin transitioned to the provider’s side.

“I guess I got a little burned out being on the payer’s side,” she stated.

She joined Brundage Group initially supporting denial management efforts. Around the same time, she began collaborating with Dr. Rao on what would eventually become Brundage Group’s DRG Integrity service line.

“Dr. Rao told me we were going to build a DRG program,” Robin said. “I’ve been involved from the beginning, helping develop the rules, workflows, and processes that support what we’re doing today.”

That work continues to evolve as Robin develops sophisticated review rules designed to identify claims with the highest likelihood of denial risk, documentation concerns, or reimbursement opportunities.

Why Denial Prevention Matters

While many organizations still view DRG reviews primarily as a revenue optimization strategy, Robin believes the industry’s biggest opportunity today is denial prevention.

With clinical validation denials continuing to increase, Robin sees firsthand how payer scrutiny affects hospitals and health systems.

“There’s really no end in sight to the denials,” she said. “The best opportunity is to catch issues before billing and give organizations a chance to address them proactively.”

That proactive approach is one of the reasons she strongly believes in pre-bill DRG review.

“Getting it right the first time is really what we’re trying to do,” Robin explained. “If organizations can identify documentation concerns, coding risks, or potential denial issues before billing, they’re in a much better position than trying to fix everything after the fact.”

A Different Approach to DRG Integrity

When asked what sets Brundage Group apart from other vendors, Robin points to the depth of review and the collaborative expertise behind every recommendation.

That multidisciplinary approach allows Brundage Group to identify risks that might otherwise be missed while helping organizations avoid recommendations that could create future denial exposure.

“We’re not interested in recommending something simply because it increases reimbursement,” Robin explained. “If we know it’s likely to create a clinical validation issue later, we’re going to tell the client that.”

For Robin, success isn’t measured by how many claims are touched. It’s measured by helping organizations submit accurate claims, reduce rework, and strengthen revenue integrity.

Looking Ahead

Even after more than two decades in healthcare, Robin remains energized by solving complex reimbursement challenges and finding new ways to improve the review process.

One area that particularly excites her is the opportunity to combine utilization management insights with DRG expertise earlier in the patient journey—helping identify opportunities before coding is even finalized.

“We’re always looking for ways to be more proactive,” she said. “The goal is to help organizations identify opportunities and risks as early as possible.”

That mindset—always asking what comes next and how processes can be improved—has been a constant throughout Robin’s career.

From physician billing and coding to payer audits, denial management, and DRG integrity, she’s spent more than 25 years understanding every side of the reimbursement process.

Today, healthcare organizations benefit from that experience every time she helps them prevent a denial before it happens.

And if there’s one thing Robin has learned along the way, it’s that sometimes the best way to win an appeal is to never need one in the first place

The post Spotlight: Robin Sewell — Turning Denials into Prevention appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

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

A chart came across our team recently, causing one of our coders to question whether a query was indicated without being leading. The patient was diagnosed with pneumonia, urinary tract infection (UTI), acute kidney injury (creatinine 2.52), and hypotension (MAP 65). There was an obvious Sepsis-3 query opportunity, but since the provider attributed the AKI and hypotension to dehydration, the coder felt a query could be construed as leading.

“If I query for sepsis now, could that be leading? The provider already gave the etiology.”

That hesitation is one of the most common, yet costly, reflexes in clinical documentation integrity (CDI). It stems from two separate issues. First, a misunderstanding of the current Query Practice Brief. Second, years of “payer conditioning.”

Myth #1: “The provider already answered, so a query would be leading.” 

This was the concern that gave our coders pause. And some would argue that this is “introducing a new diagnosis,” as mentioned in the current Query Practice Brief.

What the Brief Says:

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

The clinical indicators were there for sepsis; thus, a query for sepsis would not be introducing a new diagnosis.

The provider’s attribution of hypotension and AKI to dehydration does not close the door. It simply establishes one possible explanation. The purpose of the query is not to overturn that conclusion. It is to reconcile two documented facts that have not yet been connected: an active infection with SOFA-scoreable organ dysfunction and documentation attributing that organ dysfunction to dehydration.

What would make the query leading is the execution:

Playing Doctor: Stating that the AKI and hypotension are organ dysfunction due to sepsis.

Unnatural Selection: Dropping dehydration as an option or presenting only the clinical indicators supporting sepsis while omitting those supporting volume depletion.

Name Dropping: Asking the provider to confirm sepsis rather than clarify the etiology.

Keep dehydration on the table, lay out all the relevant clinical indicators, and ask the provider to clarify what is driving the findings. The provider’s prior documentation is not an obstacle. It is simply one of the possible answers.

Myth #2: “Maybe dehydration really does explain it.” 

This is a related myth, and it is largely payer-driven.

The premise is that fluid-responsive hypotension or AKI cannot really represent sepsis. Querying, therefore, becomes chasing a diagnosis that will eventually be denied. This is where payer conditioning has quietly influenced how CDI specialists and coders think.

It is worth going back to the actual Sepsis-3 definition.

Sepsis-3 (Singer et al., JAMA, 2016) defines sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, with organ dysfunction operationalized as an acute increase in the SOFA score of 2 or more points attributable to the infection.

Hypotension drives the cardiovascular component. A MAP below 70 contributes one SOFA point. Creatinine drives the renal component. A creatinine between 2.0 and 3.4 mg/dL contributes two SOFA points. A patient with documented infection, a MAP below 70, and a creatinine of 2.52 already has a SOFA score of 3.

Nothing in the Sepsis-3 definition requires that organ dysfunction persist after a fluid bolus. The familiar “despite adequate fluids” or “in the absence of hypovolemia” language belongs to septic shock, the sickest subset of sepsis, not to sepsis itself.

The real question is attribution. Was the organ dysfunction caused (at least in part) by the infection, or solely dehydration?

In this record, there absolutely was a basis to query. Pneumonia as a source, SOFA-scoreable organ dysfunction, and a competing dehydration explanation created genuine etiologic ambiguity. That is precisely the situation a clinical query is intended to resolve. Uncertainty was not a reason to hold back. It was the reason to ask for clarification.

The Recommended Query:

Clinical indicators in the record: 

• ED Vitals: Heart Rate: 91 (Monitored) RR: 23 Blood Pressure: 80/50 SpO₂: 94% 
• H&P: Pneumonia documented on imaging; UTI + Streptococcus agalactiae 
• Labs: Creatinine 2.52 (normal baseline); WBC 14 
• Treatment: IV Fluids administered 1.75 liters; Vancomycin/ Zosyn IV ABX 
• Progress Note: Pneumonia, UTI, AKI and hypotension documented secondary to dehydration 

Query:

The record reflects active infections (pneumonia and UTI), as well as concurrent AKI and hypotension currently attributed to dehydration

Please clarify the etiology of the AKI and hypotension:

• Due to hypovolemia/dehydration 
• Due to sepsis secondary to pneumonia 
• Due to dehydration and sepsis 
• Clinically undetermined 
• Other (please specify) 

Notice what the query accomplishes:   

Any Query Response is a Win!

Regardless of how the provider responds, the record is stronger.

If the provider attributes the findings to sepsis, the diagnosis has been captured through a compliant, non-leading query. If the provider confirms dehydration as the sole etiology, the ambiguity has been resolved, and the documentation is stronger.

Either way, the objective has been achieved. A compliant query is not about obtaining a particular diagnosis. It is about replacing ambiguity with clarity. Clarity is what stands up to audit.

The post Query IQ: “But the Provider Already Labeled it” appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

• 1,438 procedures and services remain on the IPO list in CY 2026.
• CMS proposes to remove 637 less-complex services (approximately half of the remaining IPO services) from the following clinical families: auditory, digestive, endocrine, female genital, hemic and lymphatic systems, integumentary, male genital, maternity care and delivery, mediastinum and diaphragm, respiratory, and urinary in CY 2027.
• CMS will maintain the remaining clinical families through CY 2028.

The absence of a procedure from the IPO should not be interpreted as only appropriate in the hospital outpatient setting (70 FR 68696). CMS has emphasized the expectation that, in every case, the physician or surgeon and hospital will exercise their professional judgment and assess the risk of the procedure or service to the individual patient while considering the site of service and acting in that patient’s best interest (65 FR 18456). For procedures not included on the IPO, CMS will rely on the practitioner’s judgment to determine on a patient-by-patient basis whether or not a particular procedure is most appropriately performed in the inpatient setting (70 FR 68698).

• If CMS finalizes its proposal to remove these services for CY 2027, the remaining 801 procedures, which are more clinically complex in nature, would be removed from the IPO in the final transition year, CY 2028.
  • The remaining procedures are from the neurological family, cardiovascular family, solid organ, intestinal, and islet cell transplants and related services.
  • CMS agreed to wait to remove these more clinically complex and unique procedures, as well as certain invasive procedures involving craniectomy, craniotomy, and/or burr holes and cardiovascular procedures, until the last phase (90 FR 53788).

Today, if a procedure is on the IPO list, Medicare has already decided it warrants inpatient care. The ability to automatically bill these procedures as inpatient, regardless of the patient’s actual length of stay, disappears once the procedure is removed during the phase-out process.

Documentation becomes the deciding factor, not the procedure. For any procedure removed from the list, CMS expects the physician to make the inpatient-versus-outpatient call based on the individual patient. There’s no default answer anymore.

The two-midnight rule moves to center stage. Once a procedure comes off the IPO list, physicians need to document why they expect the patient will need two or more midnights of hospital care for Medicare beneficiaries, whether that’s driven by the complexity of the procedure itself or by something specific to the patient: comorbidities, risk factors, expected complications. Weak, incomplete, or missing documentation is exactly what invites a future medical necessity denial.

More cases will need Physician Advisor input in real time. As the IPO list disappears, more borderline cases will need a second clinical opinion to confirm inpatient status is appropriate, ideally before the claim goes out, not after a denial comes back.

This is a multi-year trend, not a one-time change. By CY 2028, the IPO list will go away entirely. Physicians and hospitals will be adjusting to this every year until that time, with the most complex procedures (cardiovascular, neurological, transplants) removed last.

The March 2026 Medicare Payment Advisory Commission Report to Congress on Medicare Payment Policy found, “about one-quarter of the decline in inpatient stays per capita since 2019 was from the shift of knee and hip replacements from inpatient to outpatient settings” following their removal from the inpatient-only list. To provide more perspective, in 2018, MS-DRG 470 (Major Joint Replacement without MCC) ranked first in both FFS Medicare volume and payments. Since then, it has fallen out of the top ten MS-DRGs with a 66% decline in inpatient volume.

The removal of hip replacements from the IPO list in 2018 provides a window into what hospitals can expect as procedures are removed until the complete elimination of the IPO list by January 1, 2028. The loss of the IPO list will further erode hospital margins without adequate documentation to support inpatient medical necessity. Although there will be an initial moratorium on medical necessity denials for these removed procedures for Medicare beneficiaries, private payers who base medical necessity decisions on the IPO list have no such mandate. Consequently, hospitals must act quickly to adjust to this significant change in medical necessity criteria for surgical cases.  

More cases will need UR review. Hospitals are already spending more on administrative functions associated with the clinical revenue cycle due to rising denial rates. The IPO list phase-out will put more strain on limited utilization review staff by increasing the volume of cases. Additionally, because these cases automatically qualified for inpatient services based solely upon the planned procedure, the industry lacks adequate tools to support this shift in review priorities. This uncertainty is likely to increase denial volumes immediately for payers who voluntarily made status determinations using the IPO list.

The post The End of the Medicare Inpatient-Only List appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Hospitals know the value of Physician Advisors — but building and sustaining an internal program is harder than it looks. Recruiting experienced clinicians, maintaining consistent coverage during evenings and weekends, and managing peak demand can all strain even well-resourced teams.

That’s why more hospitals are turning into flexible, hybrid Physician Advisor models that extend or enhance their existing capabilities. Rather than a one-size-fits-all approach, these arrangements allow organizations to select the level and type of support that best fits their specific needs, budget, and goals.

How Brundage Group Supports Your Team

Brundage Group’s Physician Advisors work directly alongside utilization management, coding, and denial management teams. Leveraging analytics and purpose-built technology, they identify at-risk cases early, ensuring appropriate patient status to increase appropriate reimbursement and help prevent avoidable denials.

Depending on your organization’s needs, Brundage Group provides:

• Flexible coverage during evenings, weekends, or high-volume periods
• Team augmentation to supplement your existing Physician Advisor staff
• Specialized expertise for complex cases and payer negotiations
• Expert Peer-to-peer support from scheduling through facilitation
• Documentation improvement and DRG optimization
• Workflow strengthening across utilization management processes
• Revenue protection while maintaining compliance

The Strategic Case for a Hybrid Model

For CFOs, hybrid Physician Advisor arrangements offer a compelling alternative to adding permanent headcount. They allow hospitals to scale resources to meet demand — whether that means filling coverage gaps, handling a surge in denials, or gaining specialized clinical expertise that doesn’t exist internally.

Beyond staffing flexibility, partnering with Brundage Group provides advantages that are difficult to replicate in-house:

• Broader perspective: Brundage Group’s advisors bring insights drawn from experience across dozens of health systems, not just one.
• Benchmarking and analytics: Access to industry data and a proprietary workflow platform that reduces delays, surfaces hidden revenue opportunities, and improves compliance.
• Reduced operational burden: External physician-led support lets internal teams focus on core clinical priorities rather than administrative complexity.
• Proven methodologies: Best practices in mid-revenue cycle management, delivered by experts who do this work every day.

Protecting Revenue in a Tightening Environment

As payer scrutiny intensifies and reimbursement rules grow more complex, hospitals need solutions that combine clinical expertise, technology, and adaptability. A hybrid Physician Advisor model does exactly that, protecting revenue, supporting compliance, and reinforcing long-term financial health without the overhead of a fully internal program.

Whether you’re looking to strengthen an existing Physician Advisor program or need targeted support with denials, utilization management, or automation, Brundage Group is ready to help.

The post The Hybrid Physician Advisor Model appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Part 3 of a 3 Part Series

In Part 1 of our series, we explained how the draft 2026 ACDIS/AHIMA Practice Brief addresses compliance with technology-generated and AI-assisted query standards. In Part 2, we clarified the Brief’s guidance on compliant query practice and its relationship to claim denials. In this final installment, we focus on the core issue: what documentation supports code assignment and why a compliant query response suffices once it becomes part of the permanent health record.

The draft of the updated 2026 ACDIS/AHIMA Practice Brief, “Guidelines for Achieving a Compliant Query Practice, dispels some common myths associated with clinical documentation, like the idea that a diagnosis must be documented throughout the health record to be reportable. This is not a requirement within the Official Guidelines for Coding and Reporting. The reality is that supportive clinical indicators will be present; otherwise, there would be no justification for a query. However, the terminology used to describe the condition may only be documented in ICD-10-CM terminology within the query. That is the whole purpose of a query: to represent the patient’s clinical scenario and the provider’s intent in terms that align with the billing code set used in that setting.

Payers often cite “the diagnosis only appeared on the query,” or the lack of consistent use of the coding term throughout the health record, or the absence of the diagnosis (in ICD-10 language) in the discharge summary as reasons to remove a clinically significant diagnosis that meets reporting requirements from the claim. Often, queries are issued to obtain an impactful diagnosis (e.g., one that adds a CC or MCC to the claim) that is clinically valid and reportable for inclusion in the discharge summary. This is a huge waste of limited resources and is annoying to most providers. The reference to diagnoses being in the discharge summary is from old coding guidance that advised that the principal diagnosis be listed and that all secondary diagnoses appear in the final diagnosis list or be reflected in the final diagnostic statement. However, since that time, coding guidance explicitly states that coders must review the entire record for diagnoses (not just the discharge summary).

The draft brief specifically states, “If a compliant query has been properly answered and authenticated by a responsible provider and is part of the permanent health record, it is sufficient for code assignment. The response to the query is not required to be repeated elsewhere in the health record.” When querying was first introduced, the preferred query format was open-ended, and the response had to be documented in a subsequent medical record note because there was no other way to include it in the permanent health record. In fact, CDIs used to spend a lot of time following up with providers to remind them to document their query response within the health record.

Open-ended queries were difficult for both the provider and the query professional. The provider did not know coding terminology, so the query response often failed to yield the desired result of clarifying existing documentation into terms that translate into diagnosis codes. The shift to multiple-choice queries began while health records were paper, but became the preferred query format during the transition to EMRs because it added efficiency to the query process for both query professionals and the provider being queried. Additionally, multiple-choice queries provide the provider with coding terms that appear to align with the clinical scenario, thereby increasing their efficacy.

One of the most important inclusions in the draft is the statement that “There is no specific direction as to where a diagnosis must be documented or how often the diagnosis must be documented to allow it to be reported.” Although the query practice brief, once finalized, is only industry guidance, this is an important statement to include in appeals when a diagnosis is challenged because it is documented using ICD-10-CM terminology only once.

Appealing payer denials can be a cumbersome task that requires more than coding or clinical knowledge. In today’s healthcare environment, where profits are limited for both payers and hospitals, those appealing payer denials need to be experts in healthcare regulations, coding, and medicine.

As query expectations change, healthcare organizations need practices that are both compliant and trustworthy, supporting accurate documentation and provider confidence.

The post 2026 Practice Brief Draft: Sources of Documentation for Claims Data appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Part 2 of a 3 Part Series

In Part 1, we explored how the draft 2026 ACDIS/AHIMA Practice Brief addresses technology-generated queries and affirms that AI-assisted documentation tools must meet the same compliance standards as traditional queries. In Part 2, we cover another key update: the Practice Brief’s effort to redefine compliant query practice and clarify how the guidance should, and should not, be used in payer reviews and claim disputes.

An unintended use of prior query practice briefs was their use as a payer denial tool. Query experts Cheryl Ericson, Senior Director of Clinical Policy and Education, and Robin Sewell, Lead Clinical Coding Analyst at Brundage Group, presented at last year’s National ACDIS conference on this topic. The updated 2026 ACDIS/AHIMA Practice Brief, “Guidelines for Achieving a Compliant Query Practice,” addresses this topic head-on by discussing the draft’s intent and limitations.

First, it is important to acknowledge the elephant in the room. Even though physicians are independently reimbursed for the services they provide, their documentation serves not only as the basis for their professional reimbursement but also impacts hospital finances. Clinical documentation impacts hospital reimbursement through a variety of mechanisms, ranging from determining patient status to MS-DRG assignments to performance on quality-of-care measures. Because clinical concepts often lack alignment with clinical code sets, queries are a necessary “communication tool” used to “ensure documentation integrity and the accuracy of diagnosis, procedure, or service code assignment for an individual encounter in any healthcare setting.”  Queries “support accurate, complete, and clinically valid documentation” so the provider’s intent can be reflected within administrative (claims) data.

The basis of ethical and compliant querying is identifying clinical misalignment with coding concepts that can result in an inaccurate representation of the patient when their encounter must be explained and justified using diagnosis and procedure codes. As payers look to cut expenditures, some have found success by removing diagnoses from claims when they determine a query is “noncompliant.” Their reasoning appears to be that the diagnosis obtained from a query the payer considers noncompliant is the fruit of the poisonous tree and, therefore, must be excluded.

The authors of this updated brief address this payer trend by clearly stating that the brief, “is not intended for use as a basis for denying claims or disputing clinical queries.”  Furthermore, it states that use of the brief “as a stand-alone rationale for claim denials, post-payment recovery, or adverse audit findings is inconsistent with its purpose and scope.” It is sufficient for query professionals to demonstrate “substantial compliance,” meaning the query meets general query requirements even if it may include an “isolated technical deviation, such as a minor formatting inconsistency, a missing source date on a single indicator, or a query title visitable to the provider that is descriptive but not diagnosis-directing.” In other words, the brief was never intended to serve as a payer-denial manual.

The 2026 Practice Brief Draft reinforces an important principle: compliant query practice is designed to support documentation integrity and accurate representation of the patient story, not serve as a standalone basis for claim denials. By clarifying the concept of substantial compliance and reaffirming the intended purpose of queries, the draft provides meaningful guidance for organizations navigating increased payer scrutiny.

Next week, we’ll explore “Sources of Documentation and Claims Data,” examining how the Practice Brief addresses the clinical evidence, documentation sources, and administrative data that support compliant query practices and accurate code assignment.

The post 2026 Practice Brief Draft: Defining a Compliant Query Practice appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Part 1 of a 3 Part Series

The draft of the 2026 ACDIS/AHIMA Practice Brief, “Guidelines for Achieving a Compliant Query Practice,” reflects a sophisticated understanding of the modern documentation environment. The authors wisely include the ambulatory and professional fee environments, recognizing that the impact of documentation integrity is no longer confined to the hospital setting and MS-DRG methodology. This draft serves as a powerful reminder that while industry tools are changing, the core mission remains the same: ensuring the health record accurately reflects the patient’s clinical story.

This update is timely with the U.S. Department of Health and Human Services (HHS) and the Office of Inspector General (OIG) signaling increased scrutiny of AI (artificial intelligence) use in healthcare. As we move deeper into an era that feels like an AI arms race, this draft provides impressive thoroughness. It takes a proactive stance regarding the evolving role of technology and the integrity of clinical documentation. By moving beyond high-level mentions to provide a structured compliance framework for technology-generated queries, ACDIS and AHIMA have provided the industry with a much-needed roadmap. The workgroup deserves significant praise for tackling these complex, “front-line” issues with clarity and foresight.

The draft’s additions on AI governance are essential, as hospitals must balance point-of-care documentation efficiency with billing compliance. Specifically, the brief recognizes that technology is being “increasingly integrated” into electronic health records and expands the definition of querying to include “prompts, nudges, advisories, alerts, or similar terms” for technology-generated documentation clarification opportunities. The brief also attempts to close the query terminology loophole by declaring that “a communication constitutes a query when it presents a provider with a specific diagnosis or documentation option for consideration in connection with a specific patient encounter.” As with prior briefs, this one argues that regardless of what terms are used to describe a documentation clarification tools or when clarification is requested during the encounter, “technology-generated queries are subject to the same compliance standards as manually constructed queries.”

In this article, we looked at how the 2026 Practice Brief Draft addresses technology-generated queries and applies the same compliance standards to AI-assisted documentation tools as to traditional queries. Next week, we’ll focus on another important part of the draft: “Refining a Compliant Query Practice.” We’ll share practical tips for healthcare organizations to improve their query processes, engage providers, and maintain accurate documentation as technology continues to evolve.

The post 2026 Practice Brief Draft: Technology and Querying appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

In 2009, early in his emergency medicine career at Morton Plant Hospital, Dr. Smith met Dr. Tim Brundage.

“At the time, I didn’t think much about it beyond just having a good conversation,” Dr. Smith recalled. “But I always remember him. He was easy to talk to, thoughtful, and clearly cared about people.”

Years later, after building a career that spanned emergency medicine leadership, hospital administration, and the payer side of healthcare, Dr. Smith would once again cross paths with Dr. Brundage, this time as part of the team at Brundage Group.

That full-circle moment reflects much of Dr. Smith’s approach to healthcare today: relationships matter, collaboration matters, and behind every operational challenge are people trying to do meaningful work.

Over the course of his career, Dr. Smith has worked across nearly every corner of healthcare, from paramedic and phlebotomist to emergency physician, department leader, and payer-side physician reviewer. Those experiences gave him something many healthcare professionals never fully see: the perspective from both sides of the system.

Speaking Different Languages, Chasing the Same Goals

After years spent in clinical leadership and administration, Dr. Smith noticed a recurring challenge inside healthcare organizations.

In many cases, teams are not necessarily working against one another. They are simply operating under different pressures, priorities, and expectations.

“Clinical leaders, financial leaders, and operational leaders are often trying to accomplish the same things,” Dr. Smith explained. “But they’re speaking different languages.”

For clinicians, the focus is on delivering quality patient care. For hospital leadership, it maintains operational stability while continuing to serve the community. For financial and utilization management teams, it is ensuring the organization can sustain that care long-term.

The problem, according to Dr. Smith, is that those efforts often become siloed.

Departments can unintentionally end up operating independently, managing their own fires, metrics, and responsibilities without the time or resources to fully align with one another.

That disconnect creates friction, slows decision-making, and often increases the burden placed on already overwhelmed clinical teams.

The Role of a Trusted Advisor

Dr. Smith believes Physician Advisors play a critical role in helping bridge those gaps.

That perspective became even clearer after Dr. Smith transitioned to the payer side of healthcare.

“There were so many things I remember thinking, ‘I wish I had known this earlier,’” he said. “Simple things that could have helped hospitals and physicians tremendously if we had understood how documentation and medical necessity were being evaluated.”

Now working as a Physician Advisor with Brundage Group, Dr. Smith uses those experiences to help hospitals navigate increasingly complex payer expectations, patient status decisions, and documentation requirements.

Rather than adding to the administrative burden clinicians already face, he believes Physician Advisors should function as collaborative partners who simplify complex processes and provide clear, actionable guidance.

“If clinicians have trusted support behind them, they can focus more of their attention on where it belongs, on patient care,” he explained.

Turning Insight Into Action

As healthcare continues to evolve, Dr. Smith sees the need for proactive support becoming even more important.

Hospitals today are balancing staffing shortages, growing payer scrutiny, changing regulations, and increasing operational demands, often all at once. Many organizations are forced into a reactive cycle simply because they do not have the time or resources to stay ahead of every change happening across the industry.

That is where the combination of physician expertise and proactive analytics becomes especially valuable.

Through solutions like Certus Radar, Brundage Group helps hospitals identify patterns, recognize emerging risks, and address issues before they escalate into larger operational or financial problems.

For Dr. Smith, the value is not simply in preventing denials or improving the accuracy of patient status. It is helping hospitals achieve stronger alignment between the people delivering care and the systems that support it.

Building Stronger Partnerships in Healthcare

At the center of Dr. Smith’s philosophy is a simple idea: healthcare works better when people trust each other.

Whether he was leading an emergency department, reviewing cases on the payer side, or supporting hospitals as a Physician Advisor today, Dr. Smith has consistently focused on helping people work together toward shared goals.

Because ultimately, the challenges facing healthcare are rarely solved by one department alone.

They are solved through collaboration, communication, and trusted partnerships that help organizations move forward together.

The post Spotlight: Dr. Gregory Smith – A Career Built on Understanding Both Sides appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

What Role Does Technology Play in Hospital Revenue Cycle Operations?

“Technology is the connective tissue behind what our clinical experts do every day,” says Fulmer.

Brundage Group uses healthcare analytics and workflow technology that automatically identifies missed documentation and coding opportunities, preventing revenue leakage for hospitals.

The organization’s technology integrates with electronic health records (EHRs) and operational workflows, combining clinical, coding, and financial data into a single view to identify areas in need of attention.

Our tools highlight mismatches between clinical care and reimbursement, Fulmer explains. This enables physician advisors and Clinical Documentation Integrity (CDI) specialists to prioritize their efforts for greater impact.

What Is the Mid-Revenue Cycle?

The mid-revenue cycle is the stage between patient care and reimbursement, during which hospitals manage clinical documentation, coding accuracy, utilization review, and revenue integrity processes.

“It’s where what the clinician did at the bedside gets translated into accurate documentation, coding, and ultimately a clean claim,” says Fulmer.

Accurate documentation during the mid-revenue cycle is essential because it affects:

How Does Workflow Automation Improve Hospital Operations?

Healthcare workflow automation reduces manual steps, streamlines hospital operations, and directly improves efficiency by allowing staff to focus on complex tasks.

Brundage Group uses intelligent workflows to automate:

• Case prioritization
• Query routing
• Worklist generation
• Opportunities
• Risks

“Every hour we give back to a CDI specialist or Physician Advisor is an hour spent on the cases that matter most,” Fulmer explains.

How Can Healthcare Technology Support Clinicians Without Adding Complexity?

Fulmer believes healthcare technology should integrate into existing workflows rather than force clinicians to change their workflows.

“Good technology should feel like a quiet assistant, not another inbox,” Fulmer explains.

Why Are Fragmented Healthcare Systems Inefficient?

One of the biggest operational challenges hospitals face is fragmentation between systems.

“A single patient encounter touches EHR systems, coding, CDI, utilization review, billing, and multiple other platforms that often don’t communicate effectively,” Fulmer says.

Disconnected systems create:

• Duplicate work
• Incomplete information
• Delayed decisions
• Administrative inefficiencies
• Increased labor costs

“The inefficiency isn’t in the people,” Fulmer explains. “It’s in the gaps between systems.”

Fragmentation is not the only issue hindering hospital operations; legacy systems also struggle to keep pace with current demands.

Many hospital systems were built for a healthcare environment that no longer exists.

“A lot of hospital infrastructure was designed for fee-for-service environments with simpler payer requirements and lower data complexity,” Fulmer says.

Today, hospitals face:

• Larger data volumes
• More payer scrutiny
• Complex reimbursement models
• Increased regulatory requirements
• Faster operational demands

“Legacy systems were built to document what happened,” Fulmer explains. “Modern healthcare organizations need systems that can interpret risk, surface opportunities, and support proactive decision-making.”

How Does Technology Help Address Hospital Workforce Challenges?

Hospitals continue to face workforce shortages across CDI, coding, case management, and physician advisory roles.

“These are highly specialized roles that are difficult to recruit and retain,” says Fulmer.

Brundage Group uses technology to decrease administrative burden by automating routine processes, freeing clinical experts to focus on higher-value patient care decisions.

 How Is AI Changing Healthcare Revenue Cycle Management?

According to Fulmer, healthcare is moving from reactive systems to predictive systems powered by AI, enabling earlier identification of denial risks and more proactive revenue management.

“We’re moving from systems that record what happened to systems that anticipate what’s about to happen,” he says. hospitals that embrace this approach will operate very differently in the next five years,” Fulmer predicts.

Why Is Human Expertise Still Essential in Healthcare Technology?

Despite advances in AI and automation, Fulmer emphasizes that technology alone cannot replace clinical judgment.

“A flag from an algorithm is only a hypothesis,” he says. “It still takes a physician to determine whether documentation accurately reflects the patient’s condition and the care delivered.”

That is why Brundage Group maintains a physician-led approach to revenue integrity and clinical documentation improvement.

“The technology accelerates the work,” Fulmer explains. “But the decisions that affect compliance, reimbursement, and patient care still require clinical expertise.”

Why Does Revenue Integrity Matter for Hospitals?

According to Fulmer, strong revenue cycle performance directly affects a hospital’s ability to serve its community.

“A hospital that captures the revenue it has earned is a hospital that can retain staff, sustain services, and continue caring for patients locally,” he says.

When hospitals maintain financial stability:

• Communities retain local access to care.
• Critical services remain available.
• Staffing stability improves.
• Patient outcomes improve.
• Long-term sustainability strengthens.

That’s the larger purpose behind every workflow, every algorithm, and every chart review,” Fulmer says. “Keeping hospitals open so they can keep their communities healthy.

The post How Technology Helps Hospitals Reduce Denials and Strengthen Revenue Cycle Performance appeared first on Physician-Led Advisory & Revenue Cycle Analytics.

Today’s hospitals are operating in an increasingly complex environment, marked by shrinking margins, rising payer denials, and evolving regulatory demands. In response, Utilization Management (UM) has become more than a compliance function; it is now a critical driver of both financial performance and patient access to care. Dr. Simon Ahtaridis, MPH, CHCQM, Lead Physician Advisor for the UM service line, shares how Physician Advisors help hospitals navigate these challenges and where opportunities remain.

Connecting Clinical Care with Reimbursement

As the gap between clinical care and reimbursement continues to widen, hospitals are facing a familiar challenge: delivering appropriate care that isn’t always fully reflected in the medical record. While physicians are highly skilled at diagnosing and treating patients, they are not always trained to clearly demonstrate medical necessity in documentation, an issue that has become increasingly important as payers intensify their review processes.

This is where the Physician Advisor plays a critical role. By working alongside physicians, case management, and Clinical Documentation Integrity (CDI) teams, Physician Advisors help ensure that the patient’s story is accurately captured in real time. These collaborative efforts not only strengthen compliance but also support more accurate reimbursement.

Moving from Reactive to Proactive Utilization Management

For many hospitals, Utilization Management has traditionally been reactive, identifying issues after a patient has been discharged, when opportunities to correct documentation or clarify status are limited. In today’s environment, that approach is no longer sustainable.

Competing priorities, limited resources, and complex electronic medical records can make it difficult to consistently capture patient complexity during the hospital stay. As a result, missed opportunities often translate into avoidable denials and lost revenue.

Leading organizations are shifting toward a more proactive model, focusing on early identification of patient status, stronger alignment across UM, CDI, and case management, and the use of real-time insights to guide decisions during the inpatient stay. This shift allows teams to address issues before they escalate, reduce denials, and improve overall performance.

Helping Hospitals and Communities Thrive

The impact of these challenges extends beyond hospital operations. Financial instability can directly affect access to care, particularly in rural communities where resources are already limited. When hospitals are not reimbursed appropriately, the consequences can ripple outward, impacting staffing, services, and long-term sustainability.

Addressing these challenges requires coordinated effort across clinical, operational, and financial teams. Physician Advisors play a key role in bringing these groups together, aligning priorities, and ensuring that care decisions are both clinically sound and financially supported.

At the same time, many hospital leaders lack the tools needed to fully interpret their data and identify where opportunities exist. As Dr. Ahtaridis notes, having clear visibility into performance is essential for making informed decisions. Advanced analytics can help bridge this gap, turning complex data into actionable insight and enabling a more proactive approach to Utilization Management.

As healthcare continues to evolve, so does the role of the Physician Advisor. Increasing complexity demands deeper expertise, a more proactive approach to Utilization Management, and stronger collaboration.

Ultimately, the goal is clear: ensure hospitals are accurately reimbursed for the care they provide so they can continue delivering high-quality services to the patients and communities that depend on them.

The post Spotlight: Dr. Simon Ahtaridis appeared first on Physician-Led Advisory & Revenue Cycle Analytics.