August Audit Heat: False Claims Act settlements put spotlight on upcoding

Since starting this podcast four years ago I’ve been building toward a big number. And now it’s here: 100 episodes.  And so, for today’s show, something different. A look back, and a reorientation, framed by a personal story. Today’s show is not a summation of 100 episodes of #OTR. That’s impossible as I’ve logged more than 80 hours of fantastic conversations with dozens of terrific guests. I’ll let the archive speak for itself.  Instead it’s an unvarnished, heartfelt solocast about purpose. Inspired by my guests and their insights, but colored by a recent personal experience: My dad’s stage IV cancer diagnosis. Listen in as I cover: My dad’s diagnosis and experiences in the healthcare system Reframing the record as a tool for accurate care and revenue integrity  The two-front objective: Keeping patients healthy and your doors open Getting back to people and connection A new question I plan to ask on every show, of every guest 

When you more than double your CDI staff AND turn around a culture of skeptical physicians, you’ve made an impact. That kind of transformation takes a leader who blends curiosity, initiative, and fearlessness. That describes my guest today, who has always been fearless about trying new things. Jenna Prisciandaro is the Manager of Quality Documentation and Inpatient Coding for Fort Myers, Florida based Lee Health. She's relatively new on the CDI scene, at least to me, but has already made a big impact on her organization.  Listen in as we discuss all of this, and Billy Strings:  Her incredible (and at first, reluctant) healthcare origin story from teacher to nurse, a fateful ride with her grandmother, and what it says about Jenna the person and her leadership stye Wearing two hats as Manager of Quality Documentation (CDI) and Inpatient Coding—her biggest challenge managing two departments historically at odds, while balancing quality outcomes, productivity, and revenue demands Organizational/department KPIs, and the challenges of a caseload that includes huge numbers of snowbirds to the Fort Meyers area. Rapid rise into the leadership ranks, and her role in the rapid growth of a CDI department that went from 12 to 31 staff. Winning over skeptical providers, including one who welcomed her as the “unnecessary hair I have to pluck.” Turning things around with a dedicated provider education team, patience, and CME offerings. Current initiatives and future roadmap Jenna’s love of live music which includes following bands around the country, and a great OTR Spotify playlist selection 

This episode of Off the Record is a bit of a departure: A replay of the Norwood webinar August Audit Heat: False Claims Act settlements put spotlight on upcoding. This was our second largest attended program ever, and the topic so important—recent massive OIG audits in the Medicare Advantage/risk adjustment space resulting in over $550M in financial recoupments—that I wanted to share it with the broadest possible audience. The presenter/guest, Norwood SVP of Solutions Jason Jobes, refers to a few slides during the show but does a good job explaining them here. You don’t need visuals…but if you want the slides I’ve provided them on our website. You can find them in a link in the show notes. Listen in as we cover: What happened in two big False Claims Act settlements: $541M assessed against The Villages Health, and $14.1M against Complete Health Partners Holdings to resolve allegations of submitting false diagnosis codes/inflated HCCs. That’s not all: More OIG audits in the risk adjustment space How these recoupments impact healthcare providers—not just MA organizations “Mining” for diagnoses vs. appropriate capture Blueprint for staying on the right side of compliance Audit strategy for proactive defense  View the slides (free with registration): https://www.norwood.com/resource/august-audit-heat-webinar-slides/  View the results and analysis of the live webinar polls: https://www.norwood.com/would-your-organization-stand-up-to-a-targeted-hcc-audit-survey-says-probably-not-we-can-help/  

Trey LaCharite has seen it all during his time as physician advisor. The debut of ICD-10. The growth of value-based care and CMS pay for performance initiatives. And the rise of EHRs and the dreaded RACs. For more than a decade he’s brought that distilled wisdom to the ACDIS national pre-conference, teaching a popular seminar for physician advisors. And now he’s authored a new book from HCPro/AHIMA, The Physician Advisor’s Guide to Clinical Documentation Integrity, third edition. So yeah, Trey’s seen a lot. He’s also seen a lot of heavy metal concerts. Which is where I come in. As Trey was pouring his heart and soul and wisdom into his new book I was pouring myself into a book of my own: Growing Up Metal: The Story Of A Fan Who (Kind Of) Rocked. Now available on Amazon. This unlikely union of metalheads talk all things physician advisors, CDI, and heavy metal, as well as the trials and travails of writing, on what is a very out of the box episode of Off the Record. Listen in as we cover: Trey and his current multi-hat role as physician advisor for the University of Tennessee Medical Center. The Physician Advisor's Guide to Clinical Documentation Integrity, Third Edition ... What’s in the book and what’s new? Heavy rewrites from prior editions and a new focus on practicality. Trey’s favorite section on sepsis, and how his organization is navigating the minefield of sepsis-2 vs. sepsis-3. Trey's process of writing... “pantser” over “plotter,” and how he tackled the book with his own writing and voice (no AI, thank the lord) Working with a pair of terrific contributors—Dr. Nicole Fox and Dr. Deepa Velayadikot Documentation in the age of AI—is writing notes still important, either to a physician’s thought process or the practice of care? Trey's thought on the state of technology as useful tool vs. potential loss of autonomy. What has changed most over the years in the role of the PA: Biggest difference in job responsibilities of a PA circa 2008 and today Talking metal: Growing Up Metal questions and general metal banter, concert stories, favorite bands, and more Order Brian's book Growing Up Metal: https://www.amazon.com/Growing-Up-Metal-Story-Rocked/dp/B0HHJP531W/ref=tmm_pap_swatch_0⁠Order Trey's book The Physician Advisor's Guide to Clinical Documentation Integrity: https://hcmarketplace.com/subject/clinical-documentation-integrity/physician-advisors-guide-to-cdi-third-edition

CDI, coding, and clinical medicine are involved in a tug-of-war over a complex, life-threatening medical emergency that seems resistant to all forms of consensus. I'm talking about sepsis of course, and on today’s show I got to talk about sepsis with someone as qualified as anyone in the world to do so. Steven Simpson, MD, is Professor of Medicine at the University of Kansas in the Division of Pulmonary, Critical Care, and Sleep Medicine. He has done research in all areas of severe sepsis, from molecular and cellular mechanisms to translational and quality improvement studies. He is currently chair of the board of directors for the Sepsis Alliance and an author of the 2016, 2021, and 2025 reviews and updates of the Surviving Sepsis Campaign Guidelines. I’m also joined by James Kennedy, MD, CCS, a familiar name and voice for anyone involved in CDI and coding circles. Listen in as we cover: Dr. Simpson’s deep and rich background in sepsis, including early clinical days with septic patients, working with Drs. Bone and Balk who created Sepsis-1, and his role on the Sepsis Alliance. Co-authoring the 2026 Surviving Sepsis Guideline that defines sepsis as a “life-threatening acute organ dysfunction to infection”: His stance on sepsis-2 and sepsis-3. The politics of definition and diagnosis: Who gets to write these definitions. The struggle: Reconciling sepsis-2 with sepsis-3, further complicated by CMS’ use of sepsis-2 in its new sepsis readmission measure. What’s the right answer for this, if there is one? Looming sepsis proposal to create codes for “impending sepsis,” the role of AI-technologies (e.g., Sepsis ImmunoScore, TriVerity) in identifying these patients, and what the University of Kansas is doing to identify and intervene on infected patients before they evolve into organ dysfunctions. Plans for future work for other sepsis-related concepts, payers and denials, and a pair of songs for the Off the Record Spotify playlist.

Rose Bernards is a believer in value-based care. It’s been a driving force in her career. But it was put to the test when she suffered a family tragedy in late 2025. She wrote about that experience in a three-part series for LinkedIn I highly recommend: The Good, the Bad, and the Ugly. Link in the show notes. We get into those ups and downs, Rose’s wide-ranging educational career, and expert insights and opinions of all things risk adjustment and the mid-revenue cycle in today’s episode of Off the Record. Listen in as we discuss: Where are we today, nationally, with the state of value-based care. Is it fulfilling its mission of improving health outcomes, enhancing patient experiences, and lowering overall costs by rewarding doctors for the quality of care they deliver rather than the quantity of services they provide? What do people consistently misunderstand about risk adjustment?  Common audit findings Rose is seeing in her daily work related to documentation/coding/regulatory adherence. Great example of acute MI. Career stops at high profile organizations including Optum, First Choice Health, and working as an adjunct professor at Pacific University. The common thread? Education. What makes for a good educator? Advice for educating providers with a lesson that sticks. The story of her personal loss and how it changed her views on the healthcare system What she’s most proud of in her career, one do-over she wishes she had back, and a fine guitar-forward selection for the OTR Spotify playlist  Rose’s article “The Good, the Bad, and the Ugly (part 1 of 3)”: https://www.linkedin.com/pulse/good-bad-ugly-part-1-3-rose-bernards-l57fc  Part 2: https://www.linkedin.com/pulse/good-bad-ugly-part-2-3-rose-bernards-s3fpc/  Part 3: https://www.linkedin.com/pulse/good-bad-ugly-part-3-rose-bernards-y3ofc/  

When you work deep in the hospital mid-revenue cycle there can be an unfortunate but understandable tendency to divorce your work from the patient. To become separated from clinical care and outcomes, and even, in the case of value-based care, from its intended objective of improving affordability and quality. Those points are not lost on Dr. Sunita Varghees or Carrie Horn, who spearheaded an outpatient CDI program at Baylor Scott & White Health. One that is truly patient-centric and focused on reducing ER utilization and delivering the right level of service, not just the most profitable. Listen in as we discuss: Baylor Scott and White Health—Lay of the land of the organization and how and when they got started in outpatient CDI. “Successful risk adjustment starts with the patient”--the why of OP CDI and how their work ties into chronic condition management, not just capture. We discuss KPIs and financial metrics, too. New heart disease screening initiative—what it is, what it entails, and early successes. Is knocking down ER visits and IP admissions and getting the right level of care at the right price at odds with hospital revenue gains? Are they making it up with shared savings or care funding? Tech enabled/tech forward approach including ambient AI. Biggest success and biggest do-over, if they could do it all over again. What’s next on the OP CDI roadmap? Favorite song for the Off the Record Spotify playlist...

Cheryl Ericson is a veteran, in every sense of the word. Someone who has seen and experienced a lot in the CDI profession—and so has a wealth of knowledge and wisdom to confer. I go back a long way with Cheryl, to early ACDIS days when she was the lead educator of the CDI Boot Camp and developed the organization’s educational curriculum. She’s had a few stops since then but settled in nicely as Senior Director of Clinical Policy and Education at The Brundage Group. Cheryl is a shrewd, incisive observer of the CDI field, with a rich history of where we’ve been but also where we need to go. Recently she’s weighed in on some big mid-revenue cycle topics for ICD-10 Monitor which I read with avid interest (and recommend you do too).  In this week’s episode we hit on a few of those topics, along with a bit of a look into her life and career. Listen in as we discuss:  Formative background in nursing and entry point into CDI at MUSC. Thoughts on the new/2026 ACDIS/AHIMA query brief (currently in draft stage)--concerns with clinical indicators, her belief they are unique to each patient and may not meet guidelines established by payers: “It is not about determining if a condition exists; it should be about deciding if the physician has a reasonable expectation to treat the condition,” she writes. “Rather than asking if the condition exists, CDI and coding professionals should determine if it ‘was it reasonable for the provider to diagnose and treat the condition as if it exists.’” Pushing query compliance down to the end user—is this how the new brief reads, and if so, is it a fair expectation? Artificial intelligence: State of current tools and limitations. “GenAI tools show great promise in many areas, but for now, it does not appear capable of performing the type of complex critical thinking required for accurate inpatient coding and billing,” Cheryl observes. (Incorrect) payer allegations of hospital “upcoding,” using the example of acute blood loss anemia ACDIS heydays: A look back on teaching and educating. Her personal health journey, story of breast cancer and her husband’s simultaneous serious illness, and how it transformed her outlook on life.  Sharing wisdom and lessons learned: Career advice to a new or young CDI professional—what has she learned to pass along to the next generation?

At ACDIS 2026 I delivered an unofficial episode of Off the Record with my guest today: Tracy Ferro, Executive Director, System CDI for Medical University of South Carolina Health (MUSC). The “podcast” was delivered on stage, at the outpatient symposium. MUSC’s OP CDI program is new and being built in flight, and Tracy and I presented on it together, running the session a bit like an episode of #OTR. Full disclosure: Norwood partnered with MUSC, large academic health system, to implement OP CDI. That was a challenge! As was the Chicago presentation. On today’s episode we talk not only about MUSC’s OP CDI efforts but the presentation itself, including the prep and leadup and “game day.” And much more on Tracy’s unique leadership style and the importance of storytelling to drive home lessons (she’s wonderful at this). Listen in as we discuss: Tracy's healthcare background, a memorable nursing experience, and path into CDI. The art of leadership: Style and lessons learned from childhood and beyond MUSC’s outpatient CDI origins: The why behind the program What a pre-visit review looks like, including the use of Epic’s Enhanced Risk Adjustment Framework. Governance, workflows, reporting, and early outcomes. Outpatient CDI impact and next steps for the new program Presenting at ACDIS 2026, including tips on prep and combatting stage nerves An unexpected Sharpie arm signature and a song for the OTR Spotify playlist...

This country does a decent job in our primary schools working with children and young adults with special needs. Certainly many improvements have been made in the last 40-50 years.  But once neurodivergent kids become adults, that support seems to vanish. Tami Gomez stepped into this large breach by launching the UC Davis Neurodiversity Coding Internship Program. This new program creates professional pathways for neurodivergent individuals by offering hands-on training, mentorship, and real-world exposure to healthcare operations, specifically in inpatient medical coding. I’m thrilled to get her back on the program to talk about this, her greatly expanded role as Executive Director, Mid Rev Cycle, HIM, Coding, CDI Programs, & Revenue Integrity, and a cutting-edge new initiative she spearheaded that’s already making a big financial impact. Listen in as we discuss:  Origins of UC Davis Neurodiversity Coding Internship Program: Tami’s own story of neurodivergence Getting started—funding, early struggles and sticking points, partnership with UCLA The curriculum and beyond: What are they learning, thanks to generous donations from HCPro/AHIMA, and not just education—taking students all the way through CCS credentialing and job placement Reception from attendees and the industry at large What makes neurodivergent people uniquely able to code, and their real struggles interviewing and entering the workforce Tami’s new busy day job as Executive Director, Mid Rev Cycle. HIM, Coding, CDI Programs, & Revenue Integrity at UC Davis Health.  New Initiative: High-Pay Huddles and its financial impact Increasingly tech-enabled coding and CDI professions—are we in danger of losing them to AI? Updates on her personal life as a party planner, why her colleague Penny Jefferson rocks so much, and a new song for the #OTR Spotify Playlist... Mentioned on today’s show: UC Davis Neurodiversity Coding Internship Program: https://health.ucdavis.edu/him/Coding/Neuro.html  AHIMA video featuring Tami: https://contentwithpurpose.co.uk/ahima/healthinformation/videos/tami-mcmasters-gomez/