The Trends Reshaping RCM in 2026 — And How to Stay Ahead

Heading into twenty twenty six, revenue cycle teams are under increasing pressure to strengthen reimbursement, reduce rework, and close all of those preventable revenue leaks. Well, lucky for you, you're in the right place today because we've gathered some of the top minds in and around the revenue cycle that are gonna help us to parse through some of that complexity and nuance and really prepare us to head into twenty twenty six with clarity, readiness, and, let's say, confidence.

First up, we have Stephanie Scott with us. Stephanie also Stephanie has twenty five more than twenty five years in the trenches of health care.

And really what I love about Stephanie's background is the the variety. She's done it all from hospitals to most multi specialty practices to she's even an EHR software development.

She's a former consulting company owner, and she's helped countless practices with auditing, compliance, and revenue cycle management. And Stephanie is particularly passionate about teaching e and m coding and EMR utilization. She's one of the few people that we we look to who actually read all of those regulatory updates, and we appreciate her her interpreting them for us always.

Next, we're thrilled to have Lori Cox who brings, again, over twenty five years in health care business expertise.

Laurie is currently the director of HIM at University of Missouri, and many of you probably recognize her from HealthCon or her work traveling the country teaching complex coding topics coding on topics like HCM and oncology, and of course those wonderful E and M guidelines.

She's also served on AAPC's National Advisory Board, so she really does know our community inside and out.

And rounding out our panel of experts today is our very own Rachel Davis. She's the coding manager or she's the manager of coding services right here at AAPC. Rachel is known for being fearless about questioning the status quo, which, you know, that's exactly what we need in today's rapidly changing environment. She's got deep expertise in implementing software solutions and driving process improvements that actually work in the real world.

Lots to cover with our panel of experts, so let's just dig right in. We're gonna just kinda categorize today's discussion around these four pillars. First, we're gonna talk about, you know, the the big gorilla in the room, this denial crisis. We're we're gonna talk about what what we're seeing out there and maybe even what's causing a lot of this.

Then we're gonna look at a little bit more of that causation and correlation and look at some of the factors that are coming together. We call this the perfect storm that that are these factors that are coming together that are really making a big impact and then what we can do about that.

Then we'll take a look at some of the data from from this year, and actually let the data speak to what it is that that is distinguishing those teams that are succeeding from those teams that are falling behind. And then as always, we'd like to give you some takeaways and some things that you can go out and do today and put into practice.

So let's just start with what every revenue cycle leader is experiencing firsthand.

Claim denials.

I'm sure you're all feeling it. They have increased across all health care settings with, some pretty scary data points here. Pro fee service coding related denials up one hundred and twenty six percent.

Hospital inpatient related denials are rising nearly two hundred percent.

And with all of those denials, we still gotta maintain our benchmarks. Right? We still gotta hit those ninety five plus accuracy rates, some of us getting through hundreds of claims per day. This denial crisis has got to be addressed, but it all kinda starts with that documentation. Right?

Rev cycle teams, you and your your professionals, you're at the the heart of every single claim, every single dollar that's earned in health care. So let's start with that documentation.

And for our panel here today, question for you. What what accuracy rates are you actually seeing compared to twenty twenty three, twenty twenty four previous years? Stephanie?

Yeah. Thanks, Desiree. Appreciate that. So it's it's been really interesting to look back at accuracy rates with our data of of all the hundreds of different organizations that we work with year to year.

And it's interesting to then talk with these different organizations and talk with the chief operating folks and the CFOs and and folks like that. And really, the the crutch of these denials is coming from inaccurate or incomplete or inconsistent documentation and coding. Right? And it's interesting to see that these executives within your organizations are finally starting to realize it all starts with accurate documentation so that it they could be coded correctly so that the claims could be pushed through, reported correctly, and processed correctly on the back end and things like that.

So it's really interesting that we're starting to see their active engagement into the HIM departments and into the coding and billing departments more than I've ever seen before because that documentation is is the root of of cause analysis here. And it's interesting. We'll we'll get into some more detailed slides, but we've saw some, you know, lower accuracy rates with E and M with the implementation of the twenty one and twenty three E and M guidelines and we expected to see those very quickly climb back up to the ninety percent thresholds that we're typically used to seeing, but that hasn't been the case.

We also saw with the implementation from I nine to I ten, ICD ten scores drop and then you know fairly quickly over time, Laurie, I see you nodding your head, we saw them go up. But what's interesting, we're seeing them fall back down again.

So it's it's quite alarming in that that these trends and accuracy are are correlating with denials that you guys are all facing as well. So there's definitely a correlation between those.

Yeah. I agree. We find that a lot of it is based on documentation.

Providers really need to be as specific as they possibly can. I think when I ten first started, they kinda had a little bit of a leeway on the unspecified diagnosis, but now those denials are starting to ramp up, and they're they're just not paying them with those unspecified codes.

A lot of the clients we have that have good provider education, those are doing very well because they nip that in the bud very fast on documentation, what's needed.

You get providers onboard immediately when they start, and that helps a lot.

And, unfortunately, you can't pinpoint a specialty. It's everywhere. It's literally every specialty across the board. And and like we said, prophy, hospital, it's DME.

It's it's everything. And these denials are crazy. And I see I think Lee in the chat was saying downcoding, and there's two parts of that. Right?

There's the downcoding that the providers are undercoding, but there's the downcoding that the insurance payers are doing and not giving you an explanation. Right? And my other frustration is, like, with when you submit, like, a nine nine two zero four for a new patient and they just change it to a nine nine two one four. Again, no explanation, and you can try to fight it, and then it just becomes this nightmare.

So the documentation definitely has to support it, first of all. Otherwise, you have no leg to stand on, and then you're just writing stuff off, and we don't want that either. So it's it is a crisis. It's going up.

It's a problem.

And I think I know, Stephanie, you and I have talked before about providers not fighting them, just writing them off and tossing them to the side and saying, we're not even gonna appeal. But you're wasting so much money that you can probably afford to hire two or three people and still make money on your appeals. Right? And because it's ridiculous. So it's crazy.

Absolutely.

So this is there's there's a lot going on here. You know? Obviously, it's hard to just just put an arrow on one specific thing.

There's there's systemic challenges too. Right? And sometimes that requires multiple interventions.

Let's take a look.

Stephanie, maybe you can help us to just get an overview here of some of the historic, changes that are coming for twenty twenty six. Absolutely.

When, back in July when the proposed rule came out, you know, we're we look at those rules, and we're looking for coding changes and rule changes and documentation changes. And I was surprised a little bit to see that there wasn't that those many changes that historically we see around the code changes and things like that, particularly, you know, over the last couple years with the e and m guideline changes, for example. But as soon as I started to read and dig deeper and really try to understand the proposed rule. And then, of course, when the final rule came out, I realized these are historic changes that CMS is implementing in twenty twenty six.

We know that with the new presidency, a part of their initiative is to combat fraud, waste, abuse and go about it in a meaningful way that benefits the patients, the consumers of health care.

Not just, you know, let's just, you know, combat fraud, but go about it in this different unique way. And that's where these some of these historical changes from CMS have bubbled up.

First time ever, we're having two separate conversion factors on the professional fee schedule. Right? So if you are participating in alternate payment models through different measure programs, you've got one conversion factor compared to providers and organizations that aren't participating.

What if you are in a practice that you've got some specialties that are participating in those programs and others are not?

Huge challenge right to then get your fee schedules and everything in place. Another historical change is the two point five efficiency adjustment off the work RVU. So this is a negative. It's a two point five decrease on efficiency, and it's going to be applied to non time based codes for the next three years. So we need to watch that very closely to see if they apply that efficiency adjustment to some of the these non based codes that are excluded for next year.

Another historical change is the practice expense. So those organizations that have that work off of the the the physician fee schedule for facility versus nonfacility, there's a practice expense change for that site of service.

So this is a cut for the practices that are facility based. Right? Because CMS identified, hey. It looks like there's double dipping here with reimbursement. The facility gets part of that practice expense, but then so does the provider, whereas the nonfacility practices don't. So they're trying to even the ground and even out the payment structure there.

They're reducing costs of drugs and supplies.

The biggest one of note is the skin substitute, but then also there's that whole list of high cost medications that if you're at a practice where you're getting those supplies, you could see an impact there.

And then I found this kind of happenstance that CMS chose not to utilize the AMA survey for the the RUC score. So you know how they in years past they typically work with AMA and and their committee to identify what's customary and reasonable and they assess the different codes and the value of the codes and whatnot. Well they chose not to do that this year. They chose to use independent external sources of data.

Interesting. We need to make sure we keep our pulse on some of this going into the future because it could potentially impact the future changes as as we go forward.

Lots going on there, Steph. Appreciate that overview.

And for this audience, we are actually hosting a webinar next week, which is gonna dig a little bit deeper into some of the changes for twenty twenty six. So head on over to the website. It's another free webinar just like this one if you're interested in getting your teams to join that. And I'll put up a link at the end of this webinar too where you can register for that.

So there's a lot going on here, Steph. I know you could each one of these could be its own sort of presentation.

Yeah. And, really, it wouldn't be fun if it were easy. Right? That's true.

Not you know, a lot of things coming together, but we're seeing three three big forces that are coming together sort of creating a perfect storm for us. They aren't necessarily separate challenges. They're really amplifying each other is is what we're seeing.

Contract coding creates knowledge transfer gaps, and there's there's just a host of other issues that that we're seeing come in here.

Rachel, maybe maybe you could talk speak to some of the some of the coder shortages issues that you're seeing.

I can definitely do that.

I'm sure all management is aware we are definitely in a coder shortage.

AAPC is not exempt to that. We find that a lot of, smaller practices and even some larger ones rely on a very small team of in house coders. So if maybe one coder is out unexpectedly, all of your the rest of your coders are trying to cover that. So that leads to, a higher turnover, just getting burnt out, lack of career growth opportunities sometimes within those, health systems or facilities, and even the revenue cycle being outsourced.

And, again, smaller practices are definitely a little bit more, noticing this. They're I've noticed some practices trying to co bring coders back in house. As a somebody who's been a remote coder for many, many years, that can be challenging, especially in certain areas of the country where you just don't have those that staff available. And then, again, this time of year is also very busy.

Everybody's trying to get all of their visits in before the end of the year, so you're gonna have an increase in claims and just not the staff to get that out?

That, any one of those things, again, we could we could dig a lot deeper into. We all we all appreciate the supplemental support, especially maybe in a smaller practice or maybe with some specialty expertise that we can use in contracting.

But like you said, there's issues that come from that as well, that contractor dependency.

In addition, you know, there's potential Medicaid cuts. Laurie, how are you how do we how do we see that kind of adding adding weight to the issues?

Yeah. It just adds another layer of complexity because it affects all of this from several different angles. I mean, not only do we wanna make sure that we're billing things correctly, we already talked about the denials, But now we've gotta stay on top of it even more because we're facing all these cuts that are gonna cut into our bottom line. Right?

And then how do we negotiate that? Do we look at outside like we're doing now, trying to find outside vendors to help us when they can't find like Rachel said, they're having problems finding coders too. So it's just like this perfect storm is the perfect way to say this. Right?

Because these Medicaid cuts affect everything. Can I afford to pay a vendor now? Can I afford my in house coders? Can I afford to adopt AI or even look at AI?

Or what can I use AI for to help me potentially alleviate the the pain of this? Right? So, yeah, it's it's just another complexity and take into consideration something we don't even have on this side, but what we've just talked about with the RVU and the efficiency adjustment. And how is that gonna affect us?

Right? I mean, there's so many different factors that are just coming together.

We talked a little bit about the aging population.

That affects us not only because they're going to Medicare, but if they may have Medicaid in addition, that might be cut possibly. I mean, we just don't know. We just don't know yet how this is gonna affect us.

Oh, Laurie, it's it's death by a thousand cuts.

Yes. Definitely.

Audience, maybe you can chime in on chat and let us know what are you seeing out there? What is which one of these forces contract code or coding dependency, coder shortage, AI, or your your CAC programs that are rapidly changing and evolving? Are there any of these pressure these that you're seeing really add a specific amount of pressure in your organization? And if not that, what what is it? What is is there something that you're seeing in your particular organization that is is adding additional pressures as you look into planning and preparing for success in twenty twenty six?

So, Des, while we're waiting for some of those comments to come in, I I saw one, where an attendee commented how AI coding at times is creating more work and more issues.

And that absolutely is true. We do see that with other organizations if coders and auditors, the HRN department hasn't been involved with implementing this new AI technology that's out there and isn't constantly vetting it and making sure it's it's up to date with all these changes that that come out. On the flip side, we're also seeing success in other organizations who are successfully implementing technology, techno AI technology for eligibility and other rev cycle functions and features, ambient scribe technology for providers to lighten their documentation burden. But all of these adoptions of technology has to include our expertise as coder, auditors, HIM experts to oversee the the utilization of these technologies, or you're gonna get exactly what one of the attendees commented is, you know, you're gonna get possible issues that that come up downstream.

Oh, you Absolutely.

You I mean, we could just screen that from the rooftop, Stephanie. We've had we've had a lot of, AAPC members. Obviously, everybody's wondering, well, in every aspect of life, how are the robots going to change, you know, my world, and how how is the application of this new AI technology gonna change my job, my life, how I shop, you know. Is there somebody that something that can just do my laundry for me? Can we get that figured out?

So, yeah, it's interesting because what we've seen at least in this past year here at AAPC is an increased dependence upon expertise. You you somebody somebody still has to check up on these these robots. Somebody still has to train these these engines and, and train them every time something changes and with all the nuance and in them and everything.

Like, it just it you need that human oversight.

Yeah. You're absolutely right.

And and you need that human oversight to know when there's hallucination that's happening versus real valid correct responses. Right? And and it it takes using the technology to understand when that's happening.

So, you know, it's we need to embrace it, but we need to be mindful that it's not gonna take over our job and it's not always gonna be right. Right? We we have to be the one to to guide it.

Yeah. Stephanie, I know you and your team on the auditing side, you y'all are doing a lot of that oversight for for a lot of these organizations.

So I bet you're seeing a lot, and you you do see a lot in in your auditing role as well.

Maybe we can dig into some of that data that that you're seeing.

Yes. Perfect segue here. So every year, we do a deep dive analysis of all of our audit results across our different organizations and specialties, and it's just this monstrosity of data. Laurie, you've helped me with that.

Yeah. And what we do is we compare compare year to year how things are looking. So overall, I looked back at twenty twenty four and compared that to our twenty twenty three e and m accuracy rates. And you can see that, you know, there was a slow uptick between those two years and again not at that ninety percent where we might anticipate to see it's since the implementation of twenty one and twenty three ENEM guidelines it's been a very slow climb to improve that accuracy across most of the specialties.

Like Lori said, there's not one specialty that's not impacted with these changes.

And, know, we're still seeing opportunities of over coding, under coding, and missed revenue. Right? Missed revenue is what's really concerning me because that's just low hanging fruit that if we could solve for that, we can help then focus on the over coding that's gonna put us at risk. So solving for the under and the missed revenue opportunities there.

So when we're working with AI companies, with ambient companies in particular, we're seeing that they're providing good support for the providers clinical documentation there's still gaps but they're it's starting to close those gaps just a little bit and so anything that we can do to help lessen that documentation burden from the providers then they can focus more on the back end accuracy of the coding, focus more on, oh, yeah, I need to remember to do this and definitely focus more on the patient. So it's all going to help. And again, it just starts with the the documentation that that root cause there.

Next slide, Des, if you don't mind.

Okay. So then we did the same thing when we looked at ICD ten accuracy. Now these results are for non primary care specialties. This is for, like, our surgical specialties and our other specialties.

So when we're comparing to our twenty four data and our twenty twenty three, here's where we see that huge shift that I mentioned before about ICD ten accuracy. So we climbed back up and we were hovering ninety, ninety five percent for the last couple years on on ICD ten and then last year we saw a drop and I took a sneak peek last month actually on some of the twenty five data that we're seeing and it's pretty similar to twenty four where we're still seeing a big opportunity of errors with diagnosis mostly organizations aren't adding all of the diagnosis that need to be there on a plane.

So it's your unspecified codes that Rachel mentioned as well as they're not adding everything to support the medical necessity of the service or services which will help avoid those denials.

Interesting shift in these in these numbers here, though, Stephanie, and I know that you were able to kind of identify taking taking oncology and taking a look at some of those specific errors.

Yeah. So last month when I was doing this deep dive, we, did a webinar specific to oncology.

And so I pulled this data. And to Rachel's point, the number one overall, not with every organization, but the number one, diagnosis error was unspecified ICD ten codes. So, Rachel, do you wanna talk a little bit more about that?

Yeah.

Like I kind of mentioned before, when ICD ten first started, there was that little leeway that they gave for the unspecified codes to give providers that time to kind of get that documentation specified, give them that education.

We haven't really gotten that far. ICD ten is very specified location, any different sites, and sometimes it does take a little bit of digging through the chart maybe for the physician to find that if they're seeing the patient maybe a couple years later, but it's still an active condition. It could be oncology. It could be, it could be coronary artery disease. It can be any of those major conditions that are just unspecified, but they just have to kinda look through the chart or maybe ask the patient some additional questions, and see if they can get any more information. That's that's a big one is the is the specified diagnosis. Insurance companies are really coming back on those.

It's it's an easy it's an easy out for them because you can just an automated process.

So, Rachel, when they're denying those, are they denying it for medical necessity authorizations, the service that's being performed, whether it's an office visit or an ancillary test or something, are are you seeing that that impact?

I am we are seeing a lot of that. The LCDs and the NCDs, a lot of times your specified diagnoses will be covered for a lot of those procedures, but the unspecified have been taken off. So if you don't have that specified type of cancer or location, it's not covered anymore or ulcers. Ulcers is a big one, which leads to the skin replacement also being a big cost factor next year.

We're kinda seeing it across the board.

What I'm curious about our audience. Is there an, specific element here that's that you're seeing more or less of with regards to specificity, go ahead and put it in the chat and talk amongst yourselves.

Yeah. I see a lot of them saying, like we said, the unspecified. I mean, it's a big issue, especially when it's things like anatomical, you know, like knee pain. Why would you ever use knee pain?

You know? The doctor knows which knee is hurting, I hope. You know what I mean? So it's things like that that are a little concerning.

Right?

But then sometimes you could you have to use an unspecified code. Like, hyperlipidemia is one I think that's pretty common that we use unspecified for. Right?

And the insurance company, if they're being picky, they could just deny it, and then we're back to the denial situation that we were talking about. So it's an unhappy circle.

You know what? Another impact that we really haven't discussed yet is these unspecified codes, a lot of them do not risk adjust. So if your organization are are participating in risk adjustment, whether it's Medicare Advantage, PACE, ACO, or any of those other value based programs, if we could get the documentation to that higher level of specificity, odds are we could capture a better risk category that it will bring in the additional revenue for next year.

Great point, Steph. Yeah.

Lori, do you wanna talk to us a little bit about overcoding e and m levels?

Yeah.

Because, this is, you know, this is a problem. It's and and we see it again. There's no maybe e n m, maybe ER sticks out to me as one of the specialties. Oncology, definitely, because not every patient although cancer is a very serious disease, not every patient is a level five every day.

Right? So we see the overcoating just assuming that because it's cancer, it's automatically a high complexity problem and it's high risk. That's not always the case if the patient maybe they still are undergoing treatment, but they're doing well. They're not having too many side effects.

They're manageable. Their medications are under control. Their labs look pretty decent. That's more of a four.

Right? So we see this so much or just because a patient's on maintenance therapy.

Another thing that we that just came up in our organization was a patient's on medication, and maybe they are doing labs. But if the documentation doesn't tie that lab because we're monitoring for toxicity, then we're not gonna give them high risk. We want that that to tie together. Right?

So we've had a discussion in our organization about how we shouldn't automatically assume that just because they're they're on this medication and they did this lab and they're not tied together anywhere that that's high risk. Right? So it's it's again, it's just over and over education. We need the documentation to be clear, and that kinda goes into the next one, the incomplete documentation and the copy paste.

Don't we love copy paste?

And I I'm all for templates. Don't get me wrong, but I'm I'm not for overuse of the template. Right? And it's just copy paste, copy paste, copy paste, and every documentation looks the same.

Or especially in oncology, you know, the whole patient's history is in every single no, and I get why they think it needs to be there. But if they knew how to use their EMR system a little bit better, it wouldn't have to be. Right? So, yes, units and it's not just an oncology.

It's we gave a knee injection. What did we give them? Did we give them Kenalog? Did we and how many milligrams did we get?

Not CCs because we don't code by cc. We code by milligrams. Right?

And but the status of their condition is today, like I said, with your cancer patients, how are they doing today? You know? Maybe they were very ill in the hospital last week, but today they're doing well. But if all you say is breast cancer, how am I supposed to know that they're at high risk? You know? So, yes, we have got to educate, educate, educate our providers on proper documentation.

And, yes, we can reach out to AI and get AI to help us. But as we've seen, AI is not perfect, and we still need to have that oversight.

Thank you, Laurie. Rachel, do you wanna jump in and and tell us some of the incomplete or documentation gaps that you're seeing in the coding services division?

Yes. Copy and paste is definitely a big one and the templates, not updating them. So they might be using the same templates they used five years ago, but e and m guidelines have changed. If you can use time documentation, have the providers document that time. That that will help.

It's a lot of those does I will I'd like to say easy fixes. They're not easy fixes because, you know, we it's not always easy to get providers to change what they do, but to kind of start that conversation or get the provider education.

Sometimes it's helpful with some of our smaller clients. The providers drop their own charges. Nobody looks at it. No coder, no other person until it gets denied.

So if you can have that in between to kind of do a little spot check, it kind of catches it before you have a bigger issue.

I I love that CDI approach. And I think we're gonna talk about that in a slide that's coming up. Right? Yep.

Alright. Perfect. We're ready for the next slide, Des. Yeah.

So let's look at, what do you see in here as we've as we mentioned early on, what are some of those aspects that differentiate those teams that are confident, succeeding from those that are just chasing their tails?

Right? Yeah. Oh, go ahead, Laurie.

No. You go ahead. You take it.

I was just gonna say, we find that a lot of times audits don't start until you find a problem. And then you're trying to backtrack and correct that problem after the fact.

So, facilities and health systems that start with some auditing of some sort, really, it helps, catch those things in the beginning. I found that, which can be hard with coder sir coder shortages, peer to peer audits. You don't always have to have a full official audit by somebody up above. We have a lot of peer peer to peer audits where they can audit each other, and it's more it's less intimidating.

It's more educational. There's no punitive things. It's people getting on the same page, and everybody knows what everybody else is doing. Because you can ask a room full of coders one question and get five different answers because everybody's kind of on a different page.

Yes. So those the initial audits are definitely more productive than those, oh, shoot. We have a lot of denials. Now what do we do?

Now we where do we go from here?

Laurie, what are your thoughts?

Yeah. Absolutely.

And one of my so I just started at the University of Missouri back in August, and one of the questions that I have constantly is why, or why are we doing it this way? And my answers that I keep getting is, well, that's how we've always done it, and I hate that phrase. If there was one phrase that we should eliminate from our society, it's because we've always done it that way. So no.

First of all, is it working?

Maybe. Let's investigate. And ninety times out of ten, it's not.

Right? So we need to really dig in. And, yes, it is so hard, and I see that in the chat too. It's hard to stay on top of it and do those total revenue cycle audits from beginning to end with the staffing shortages that we have.

But you've gotta do it. It's so beneficial. Even if you have to reach out to a AC or some other vendor and get them in there to do it for you, you're gonna realize where your weak spots are. And, again, that just goes back to what we were talking about earlier with the Medicaid cuts and the final rule and what is happening.

You're gonna wanna do that and find out where you're missing that revenue. Somebody asked in the chat, how do we find out who or where you're missing your audits, where you're missing your revenue? You gotta audit. You know?

You've gotta audit your total revenue cycle from the moment that patient calls and makes that appointment to the time that the claim is adjudicated. That's it's hard. I'm not gonna lie, but it's something that you do need to do.

It it is hard, but, you know, you don't know what you don't know. Right, Laurie? And there's only one way to to do that.

Data data speaks volumes. One, quite a few of the organizations that we work with are actually using, AAPC's tool Practicode in a different way. Some of you who are certified, you may have used Practicode for that a removal to try to get, all of your all of your time and and and move past, from CPCA to CPC. But Practicode there's actually a side to Practicode where, RevCycle managers can can test their teams to actually benchmark their accuracy and proficiency with real world cases, like the same cases that you would use in your practice.

And they can actually identify where their weak spots are so they can pinpoint those training opportunities. And some organizations are even finding that, oh, you know what? This coder has got some really elevated skills in a certain area, and they're in the wrong role. I gotta move them to a different seat, and they need they'd be better off in a in a specific specialty role.

Right? So, again, you don't know what you don't know, but using some of those tools and the audits to to get that is gonna help you to make those, database decisions.

Yeah. Absolutely. And I have two comments, if you don't mind, before I move on. So, Laurie, I was really happy that you brought up the point about, organizations that weren't doing internal audits because what we found at AAPC after the pandemic, a lot of work organizations either cut their compliance program or, external vendor audits or decreased it because the budget cuts. Right? We were all recovering from the pandemic. We had organizations had to pay grant money back and different things like that.

And so we saw this dip with quite a few of our customers, and then they started to see their denials increase and started to see revenues decrease. And when we came back on and started back on with their continuous audit program, and it wasn't just coding and documentation reviews, Laurie. It was exactly what you said, the full rev cycle. They started to see those numbers go back up, kinda normalize a little bit.

And so it is. It's, you know, you always need to audit. There was a a comment just a moment ago. Well, how often? Well, once a year isn't enough. It needs to be continuous.

But you also need to do it at a frequency that your organization can absorb because you don't wanna just spend money and time and effort to do an audit that you're not gonna do anything with either. So, you know, getting some external help to supplement what you're currently doing is is a good way to do that.

And then the other thing thing I wanted to mention that kind of sparked to my mind was organizations that are proactive with coders, building relationships with their providers and with the CDI team, and meeting with them on a regular basis, we see a good success in combating the the crisis and these, you know, external three forces that that we spoke about.

We could do a whole webinar on, you know, provider training and CDI connective connectivity, and maybe we will.

Alright. Let's jump into some, actually, actionable items, get some practical next steps here for the next, ninety days. Stephanie, you've outlined a couple, action steps that we can take in q one.

Yes. So, you know, I I work well when I'm given a project and a timeline and due dates. And so I'm always proactively thinking ahead. Okay.

What do I need to do next quarter and and beyond that? And so we thought it would be nice to kinda share with you some of our thoughts for the fee schedule changes, not just for for professional, but your outpatient and facility changes. You need to do a detailed analysis if your organization has not done already. And you need to redo that within q two or q one.

Right? Just so that you can see more what the impact might might be. Doing it initially can give you a hypothesis of what you might think the impact would be, but you need to understand realistically what that was.

Establishing some accuracy rates for for your baseline audits. Accuracy rates and baselines for your other audits that you're doing.

Where do you want where's your denial rates right now? Where do you want them to be? If you set some benchmarking so that the team can rally around and get together to improve those and as you're working through those denials and monitoring them and then you can start to find out well what is the cause? You know what's what's that root of the denial and you go down that branch just like the tree image of that tree that you shared does fixing that and going to the next one right and when you include the team on that not just the rev cycle manager but your team we we start to see some success. So mapping that throughout the year.

And then could that continuous employment of or deployment rather of education. Right? So important that both Rachel and Laurie spoke about and then you does, you know, making sure your team is their skills are are being extended and uplifted continually. It's so important to to to make sure that those things happen.

You can't wait. You can't just kick that can down the road. You need to, in your road map, you know, put in those different areas of where and when those educations and items need to be placed. Start assessing AI.

Right? Monitor what's happening in the industry. Talk with organizations. Talk at your local chapters. You know, how what have you implemented?

How has it gone? You know, look at the source of truth with these different technology vendors because it's important to understand what to do, what not to do, what's working, what's not working, and understand your organization because, you know, what one organization might seek success may not help you and your organization. Right? Because we're all so unique and very different.

And then just that continuous monitoring of that full rev cycle audit that Laurie said, make sure you get those incrementally in your your different quarters and making sure that you are working with the CDI team to to improve that documentation and push it forward.

Alright. Really quickly, let's let's dig in a little bit more detail with each of these action items.

Yeah. So here's a slide you might wanna just take a snippet where when you get the recording, dive a little bit deeper here that that financial impact that I just mentioned and then a few other things digging into your telehealth program. I I feel like we're at a tennis match where we're just watching the ball go back and forth.

These are the new rules. Oh, never mind. We're doing it this way. Now we're someone has to take the lead in your organization to figure this out and make sure you're you're putting things in place. My recommendation, put the most stringent rule in place and at least it will cover you going forward.

That side of service adjustments that we spoke about, you've gotta really monitor that. Look at evaluating what programs is your organization participating in or not, and have someone look into that that could help combat some of the decrease in reimbursement that you're getting is starting to participate in some of those programs.

Look at the efficiency adjustment where where, you know, the work RVUs, what services are you performing a lot of where that efficiency adjustment off that work RVU might might come into play.

And, you know, work with your chief operating officer, you know, and identify what additional services maybe your organization could put into place and, of course, staff training. We just can't say that enough.

Documentation and coding. Rachel, do you wanna address these really quickly? Sorry.

I put myself on mute instead of on mute.

Documentation and coding, that's kind of where it all starts. Utilize a clinical documentation improvement program, and implement a physician query process. Sometimes just getting one big provider on board with you and helping with the education can get the rest of them on board or at least help. At least speak that same language.

A great advice right there.

Yeah.

Use your EMR to you know, the verified documentation requirements are met.

Use your AMR. Use those manual edits you can put in. I know different Athena, Epic, some of the EMRs, can put in those if it's a level five, it's gonna stop so somebody can look at it, things like that. Use your software as much as you can.

Love that. And, of course, proactive auditing costs far less than reactive correction. That's the headline here.

And lastly, denial prevention. Laurie, do you wanna speak to this really quick?

Yeah. Absolutely. So all of these are really good ideas, but a couple that really stand out, I think, is eligibility. Not and, yes, definitely with your high cost services, infusions, your surgeries, but get it done. Do it up front. There's a lot of software out there that can help you get that done.

Confirming it kinda goes along with it. Confirming coordination benefits for Medicare and for Medicare Advantage and Medicaid and especially Medicaid nowadays.

This then MDCs and validation checks, ABN. So we found in our organization that we had a little bit of an efficiency in an ABN area. And how did we find it? We did an audit.

So that's what you you've gotta do, and that audit is the only thing that's gonna tell you if your documentation is insufficient or not.

So one thing, if you don't mind just flipping back that real quick, Des, I think this is important. We have been starting to hear organizations that are reimplementing a patient axe access person.

This is at facilities and this is also at professional service locations where they're they understand billing, they understand coding, the codes, they're working with the patient. So a lot of check-in now is happening remotely before the patient comes, right? So if they come out ask him to come early, they can sit down with this patient access person that can go over some of these checks and go over the services that are being rendered and double check a few things, get the ABN in advance, you know, different things like that. And we've seen some really good preliminary success with this this kind of not necessarily a new role, but advanced role in making sure that those patient access folks have that coding certification and rev cycle understanding.

Yeah. That's a great idea. Earlier this year, we attended Becker the Becker's conference, and everybody was struggling with pre ops in in that area of the business.

Alright. Strengthening appeals and supporting documentation.

Yeah. Like Lori said earlier, we've been hearing different organizations just can't keep up with the denials, and so they've electively decided certain types of services to not appeal. This is an area that if if you do your audits and do a root cause analysis, then you can implement certain pieces to one, hopefully, stop the denial from happening so you don't have to appeal. But then you can also implement some automated workflows for appeal. We're seeing some good success with organizations there. If you have a particular payer or a particular service across your payers that you know always get denied, have the patient implement a medical necessity statement at the beginning of those services in the medical record or even a letter particular to that patient. Proactively taking those steps can help and then your billing team they already have this in their arsenal they can you know push it through.

Know referencing the NCCI guidelines and the version a lot of times payers have third party vendors that are adjudicating these denials and they don't have the up to date information but you do your organization will so make sure that you've you've got a bulletproof arsenal building these different tools and and documents and assets that you can appeal those claims because like Lori said, oftentimes you're getting denials of the same reason. Well, if you can figure out that easy workflow, streamline that, it's worth your time and effort to hire these folks to to do those appeals.

It they will definitely pay for themself.

One hundred percent. Y'all, if we don't get to your questions today, we will possibly send out a supplemental follow-up asset that addresses them. So, if you still have questions for our experts, go ahead and submit them to that Q and A panel so that we can get to that.

A few more takeaways here.

Y'all, key regulatory resources to reference.

These date I've put a few dates on here as well just to be mindful of in case you are not already tracking them. A lot a lot a lot to follow-up on. Lots of different websites to go to. And, you know, since there is a lot to go out there and monitor, and I don't know if you have time for that. I don't. But don't worry about it. We got your back.

In addition to free webinars like this one here today, your AAPC membership is is really your key to both, personal career and rep cycle team success. It's it's your secret sauce. Tons of free resources to keep us all connected to excellence and connected to each other. So if your team's not already covered under a corporate membership with the APC, we can help to find some big cost savings at your organization.

We can also improve job performance, employee engagement, and provide a nice bonus to keep the those of your best players on your team, corporate membership. As a as the health care landscape evolves, as it always will, so should your qualifications. So we're keeping you on the leading edge with new certifications. Our newest credential recognizes rev cycle leadership as more of a comprehensive spectrum of oversight and expertise in all settings across all processes that impact the rev cycle.

So check out that one. It's called RCMS. And then in a few months, our team is gonna launch a new credential. You're hearing it here first today.

The CVBA is gonna certify you as a professional administrator who can navigate and optimize value based care with confidence. And, of course, if you're not already using Codify to supplement your workflows across your whole team, I hope you have some other encoder tool that keeps your team connected to the latest code changes, guidance, and, other claim optimizing tools. So Codify is really great because you can also earn CEUs, while while you're unifying the whole team with best practices from providers to billers, inpatient, outpatient. We even see just about every major payer using Codify, y'all, so so we can all talk the same language.

And a few treats for joining live today. You can also get your team registered for that free webinar that I mentioned earlier. That's next week where our experts are gonna dig a little bit deeper into the twenty twenty six final rule.

We're also giving you access to another free resource for rev cycle leadership. Those of you who are looking for maybe some quick tips and some some easy strategies to help, keep your teams on point, we got your blueprint for building a high performing coding team right here. And, also, just always wanna mention, we work a lot, with our friends over at Healthicity. They've just launched a new platform called Audit Manager Plus.

Helps helps a lot to centralize audit results, provide, visibility, and streamline reporting across, like, the entire compliance life cycle. So check that out if you wanna learn more. Again, we went a little bit long. So sorry.

I know everybody's time is super valuable. If we didn't get to your questions, look for us to follow-up with maybe some responses in that post event recording email that you're gonna receive. And, also, when you leave today, you're gonna be presented with a quick question. If you want to talk to one of our experts or you want follow-up on any of these, solutions that we've provided here for today, everything from we can help you with everything from pre auth, DNM, CDI, provider training, everything in between.

We've got, your back. We're all in this together.

We will soon post this recording, and, it it will go to the website as well as that email I'm entered as a registered attendee. You're gonna get that notification, the slides, and more information on revenue cycle solutions from AAPC. Sorry we kept you so long. We super duper appreciate your time here today.

Hope you found some some nuggets of gold here that you can take back and use. And we hope to see you on the next AAPC webinar. Thank you to our panel for their super duper insightful, recommendations and insights. Thanks everybody for joining us.

This concludes the webinar today.