Off the Chart: A Business of Medicine Podcast

Vaccine confidence in the United States has declined sharply, and the reasons are complicated — organizational upheaval at the CDC, conflicting guidance from different authorities, COVID-19 messaging failures and a flood of social media misinformation.

In this episode, David Dodd, president and CEO of vaccine developer GeoVax, joins Medical Economics Managing Editor Todd Shryock to share his perspective as an industry insider who is neither dismissive of the concerns driving hesitancy nor willing to accept that the system is beyond repair.

Music Credits:
Empty Spaces by Cephas - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:24 | Sponsor message Copic medical liability insurance.

0:24 – 0:50 | Cold open Dodd previews the episode's central concern: an unprecedented decline in public trust in the institutions that have historically guided vaccine decisions.

0:50 – 1:47 | Introduction Austin Littrell introduces the episode and previews the conversation with Dodd.

1:47 – 5:00 | The Vaccine Integrity Project Dodd explains why the AMA's independent vaccine review initiative matters — not because the CDC has collapsed, but because the current process lacks definition, and uncertainty is directly affecting development timelines and public confidence.

5:00 – 6:36 | Can independent review and federal oversight coexist? Dodd predicts convergence between the AMA's process and the federal government's, drawing on historical precedent for multiple parallel pathways eventually integrating into something new.

6:36 – 10:45 | The most damaging misinformation — and why Dodd pushes back Dodd names the blanket claim that Secretary Kennedy is entirely anti-vaccine as the most damaging narrative in circulation, and explains why his own company's experience — including losing a $400 million DOGE-cut program — makes him neither a hard-line supporter nor a dismisser. He also addresses the mRNA vs. multi-antigen platform debate and why preferring one over the other is a legitimate scientific conversation, not a conspiracy.

10:45 – 13:15 | Red states, blue states and fragmented guidelines Dodd says he doesn't believe the U.S. will end up with politically divided vaccine guidelines — but acknowledges the current vacuum is real and that medical organizations stepping in to fill it, while sometimes viewed as overreach, is a necessary response.

13:15 – 14:07 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

14:07 – 20:22 | How COVID-19 messaging failures bred lasting skepticism Dodd traces the roots of current vaccine hesitancy to the 2020 messaging around COVID-19 vaccines — overstated efficacy claims, promises of sterilizing immunity that didn't hold up, mandatory language that alienated the public. He argues the lesson is transparency about what vaccines actually do: reduce hospitalization and death, not prevent infection entirely. He also makes the case that measles, flu and COVID-19 vaccines require very different public conversations.

20:22 – 24:04 | Advice for primary care physicians Dodd's core message to physicians: listening is the most important clinical skill you have in this environment. He shares a personal story of switching physicians after feeling dismissed, and makes the case that patients who don't trust their doctor should be told to find another one — because the relationship only works if the communication is genuinely bidirectional.

24:04 – 25:01 | Closing remarks and outro Shryock wraps the interview. Littrell thanks listeners and reminds the audience to subscribe and visit MedicalEconomics.com and PhysiciansPractice.com.

What's really driving the dysfunction in American health care?

Longtime Medical Economics editorial advisor and family physician Melissa Lucarelli, M.D., FAAFP, sits down with Erica Rowe Urquhart, M.D., Ph.D., MBA, an orthopedic surgeon, 20-year independent practice owner and author of "The Invisible Hand Wielding the Scalpel: The Hidden Cause of America's Healthcare Crisis." The two physicians discuss why independent practitioners may be a dying breed, how insurance middlemen quietly slash physician reimbursements and why Medicare Advantage brokers are steering patients away from their own doctors with incentives patients never see. They also get into the prior authorization maze — including the frustration of reverse-engineering insurer rules that change every January, and why AI may be one of the most promising tools for cutting through administrative waste.

"It was somehow reassuring to discover that across disparate geographic areas and medical specialties, physician frustration with the health care industry seems to be universal," she told Medical Economics Senior Editor Richard Payerchin. "I believe all physicians face an arduous career journey which includes lifelong learning. Dr. Urquhart's story was fascinating... in the context of serious personal health problems, she not only continued to practice medicine, but also decided to pursue financial and spiritual enrichment though an MBA program and seminary school."

“Our conversation started with data and actionable information about how to navigate prior authorizations and managing an entrepreneurial independent medical practice, and we ended up delving into the application of artificial intelligence to our work and specific tips about how other doctors can get started developing their own podcast or publishing their own book.”

Urquhart is also the creator of the podcast "UpMed: The Journal of Healthcare's Race To The Bottom," available where you get your podcasts. 

Music Credits:
Distant Memories by Buurd - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:24 | Sponsor message Copic medical liability insurance.

0:24 – 0:42 | Cold open Dr. Urquhart previews the episode's central argument: the 21st century's undivided focus on profit does not benefit society as a whole.

0:42 – 1:27 | Introduction Austin Littrell introduces the episode and hands it off to Dr. Lucarelli.

1:27 – 5:38 | The invisible hand and the race to the bottom Dr. Lucarelli introduces Dr. Urquhart and opens with her book's title metaphors. Dr. Urquhart explains how she's reinterpreting Adam Smith's "invisible hand" as a force now driving health care in the wrong direction.

5:38 – 10:43 | Why independent practice in an underserved community Dr. Urquhart traces her mission to volunteering in a Boston NICU during the AIDS crisis and her commitment to care that's cutting edge, timely and accessible to anyone. The conversation turns to data on physician office density by state and her belief that independent practitioners may be a dying breed worth documenting for future generations.

10:43 – 15:21 | Independent vs. employed: the real trade-offs Dr. Urquhart lays out the honest pros and cons of each path. Dr. Lucarelli adds data on independent physicians' long-term compensation and lower burnout rates.

15:21 – 18:27 | The agility advantage Both physicians share how their independent practices pivoted quickly during COVID-19 — and why large health systems couldn't move nearly as fast.

18:27 – 20:47 | The podcast cliffhanger — and AI as the solution Dr. Lucarelli references the cliffhanger ending of Season 2 of Dr. Urquhart's UpMed podcast. Dr. Urquhart teases that the solutions season will focus heavily on AI and large language models.

20:47 – 26:47 | Advice for physicians who want a bigger platform Dr. Urquhart walks through practical steps for starting a podcast and why she chose hybrid publishing over traditional publishing for her book.

26:47 – 32:17 | The coffee analogy: why health care pricing makes no sense Dr. Urquhart uses the caramel macchiato analogy from her book to illustrate why the same service, the same code, can yield wildly different reimbursements. Both physicians agree the system seems designed for no one to understand.

32:17 – 35:13 | The middleman problem Dr. Urquhart explains the repricing middleman model — where insurers route claims through a second company they may partially own to cut physician payment and pocket a percentage of the reduction.

35:13 – 39:29 | Medicare Advantage brokers and continuity of care Dr. Lucarelli raises Wisconsin's $626-per-patient broker switching bonus and how patients are misled about network access. Both physicians describe winning continuity-of-care approvals only to have insurers refuse to pay the bill.

39:29 – 44:47 | Playing a game without the rule book Both physicians discuss the secret, ever-changing prior authorization criteria that force physicians to reverse-engineer insurer rules every January — and the waste it creates for both doctors and patients.

44:47 – 49:55 | Personal health crisis, MBA and seminary Dr. Urquhart opens up about a health crisis that led her to pursue a theology degree and an executive MBA — and what both taught her about leadership, recovery and running a practice.

49:55 – 55:00 | Personal reflections and the next generation Dr. Urquhart reflects on her mother's influence, her children and whether she would recommend medicine as a career today.

55:00 – 57:05 | Closing remarks and outro Dr. Lucarelli wraps the conversation. Austin Littrell thanks both physicians and wraps the episode.

Getting paid for services already rendered shouldn't be this hard. But for most physician practices, navigating insurance payments has become one of the most frustrating and resource-intensive parts of running a business.
In this episode, Roshan Patel, founder and CEO of Arrow, joins Medical Economics Managing Editor Todd Shryock to break down why health care payment friction keeps getting worse — more prior auth requirements, more denials, more fragmented systems and a chronic shortage of trained billing staff to manage it all. Patel walks through the three routes practices typically take when payment processing gets out of hand, explains where AI is genuinely helping in revenue cycle management versus where it's still more hype than substance, and argues that denials management is the single highest-impact area for technology right now.
 
Music Credits:
MUCHOS BESOS by Bopper Beats  - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:28 | Sponsor message Copic medical liability insurance.

0:28 – 0:54 | Cold open Patel previews the episode's central tension: in health care payments, one side wants to get paid and one side doesn't want to pay — making it almost a zero sum game by design.

0:54 – 1:48 | Introduction Austin Littrell introduces the episode and previews the conversation with Patel.

1:48 – 2:42 | The biggest pain points in medical payment processing Patel describes the current state: constantly changing payer rules, more prior auth requirements, rising denial rates and increasingly fragmented systems — all adding up to mass frustration across the industry.

2:42 – 4:14 | Why hasn't this been fixed? Patel explains the structural problem — misaligned incentives, fragmented payer systems, information that's nearly impossible to access without calling the insurer directly, and a staffing pipeline that keeps burning out the specialized people needed to manage it all.

4:14 – 5:28 | Three routes practices take Patel lays out the options: hire more in-house staff, outsource to a medical billing company or adopt technology. Each has tradeoffs, and knowing which fits your practice depends heavily on size and growth stage.

5:28 – 8:34 | How AI actually fits into revenue cycle management Patel distinguishes between two AI models — full automation for lower-stakes tasks like scribing, and a co-pilot approach for higher-stakes work like billing where a human needs to stay in the loop. He walks through specific use cases, including clean claims checks and AI-assisted appeal letter writing, where tasks that took hours now take minutes.

8:34 – 9:26 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

9:26 – 10:45 | Patient payments and the system-of-record problem Patel addresses the gap between insurance and patient payment systems, explaining why most practices can't answer basic questions about their own collection rates — because there is no single source of truth, and the EMR was never really built to be one.

10:45 – 12:10 | How to modernize your payment systems Patel's advice: skip the Google search and ask peers what's actually working. Smaller practices should look for one or two tools that do most of the work; larger practices can afford point solutions. Conferences are an underrated place to vet vendors in person.

12:10 – 13:15 | What metrics to demand from vendors Patel says practices should know their own collection rate and average time to payment before approaching any vendor — and then hold that vendor accountable to moving those specific numbers, not just general promises.

13:15 – 14:24 | Where technology makes the biggest difference Denials management. It's the most labor-intensive part of revenue cycle — vague denial reasons, phone calls to insurers, appeal letters, follow-up — and the area where Patel sees the clearest case for technology.

14:24 – 15:51 | The five-to-ten year outlook Patel pushes back on the idea that AI will replace medical billers, arguing that the specialized institutional knowledge experienced billers carry is something AI can't replicate. His prediction: billers stick around but become significantly more productive — and health care payments never fully loses its friction.

15:51 – 17:10 | Outro Shryock closes the interview. Littrell thanks listeners and reminds the audience to subscribe and visit MedicalEconomics.com and PhysiciansPractice.com.

Earlier this year, the Milbank Memorial Fund, the Physicians Foundation and the Robert Graham Center jointly released "Investing in Primary Care: The Missing Strategy in America's Fight Against Chronic Disease" — a detailed, data-driven report making the case that primary care is both the most effective and most underfunded tool the United States has in its fight against chronic disease.

In this special episode of Off the Chart, Medical Economics Senior Editor Richard Payerchin speaks with four of the people closest to the work: Morgan McDonald, M.D., national director for population health at the Milbank Memorial Fund; Debra Lubar, Ph.D., president of the Milbank Memorial Fund; Ripley Hollister, M.D., a family physician and board member of the Physicians Foundation; and Yalda Jabbarpour, M.D., a family physician, lead author of the report and vice president and director of the Robert Graham Center.

Together, they walk through the report's most striking findings, explain why less than 5% of U.S. health care spending goes to primary care, and make the case for what needs to change.

Read the full report: https://www.milbank.org/publications/investing-in-primary-care-the-missing-strategy-in-americas-fight-against-chronic-disease/

Music Credits:
Crystal Grind by NISO - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:28 | Sponsor message Copic medical liability insurance.

0:28 – 0:41 | Cold open A preview of the episode's central framing: America's health care system isn't broken — it's just off balance.

0:41 – 1:54 | Introduction Austin Littrell introduces the episode, the report and all four guests.

1:54 – 2:18 | Guest introductions Richard Payerchin introduces each guest by name.

2:18 – 3:50 | The state of primary care today Richard asks each guest the same opening question. The answers converge on the same theme: primary care is overburdened, underreimbursed and increasingly unable to attract new clinicians.

3:50 – 6:04 | Why primary care is best positioned to lead on chronic disease Richard asks why primary care is the specialty best suited to lead the Make America Healthy Again agenda's shift toward prevention. The guests explain why prevention has always been primary care's core mission — and why the patient-physician relationship is the mechanism that makes it work.

6:04 – 8:00 | What the data shows: prevention and the trust finding The report's prevention findings — blood pressure checks, cholesterol screening, mammograms — are contextualized, with particular focus on why patients with a primary care physician are more likely to complete cancer screenings that don't even happen in the primary care office.

8:00 – 9:56 | The pediatric findings Children with a usual source of primary care cut their odds of an avoidable ED visit or hospitalization by nearly 50%. The guests discuss why the pediatric findings may be the most important in the entire report.

9:56 – 12:36 | The cost finding Richard asks each guest what finding surprised them most. The answer is consistent across all four: adults with chronic disease who have a usual source of primary care have nearly 54% lower total health care expenditures.

12:36 – 15:14 | Where the money goes — and doesn't Primary care is preventing disease and cutting costs but receives less than 5% of U.S. health care expenditure. The guests discuss whether that number has changed, why it hasn't and what doubling it by 2030 would actually require — including a fundamental shift away from fee-for-service.

15:14 – 16:37 | The APCM code opportunity Medicare's Advanced Primary Care Management codes are flagged as a concrete policy mechanism worth watching. The guests discuss how treating primary care services as preventive — the way Medicare treats colonoscopies — could change the financial picture for struggling practices.

16:37 – 17:27 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

17:27 – 20:59 | The workforce problem and the employer opportunity The spending gap is fueling a workforce crisis. The guests describe what the staffing math looks like in independent practice, why where physicians train determines what specialty they choose, and what role large employers can play in purchasing health plans that prioritize primary care access.

20:59 – 23:46 | The one recommendation Richard asks each guest which of the report's seven recommendations they would implement first. All four point to the same broad answer: change how much — and how — primary care is paid.

23:46 – 24:58 | A message to primary care physicians The guests close with a direct message to the physicians listening: the data makes the case, the policy levers exist and the work being done on their behalf is real.

24:58 – 26:20 | Outro Austin thanks all four guests, points listeners to the full report at milbank.org and wraps the episode.

Most practices manage their revenue cycle reactively — putting out fires instead of preventing them. In this episode, Kem Tolliver, FACMPE, CPC, CMOM, CEO of Medical Revenue Cycle Specialists, joins Physicians Practice Managing Editor Keith A. Reynolds to explain what a truly strategic revenue cycle work plan looks like and how to build one that aligns with your overall business goals.

Sign up for the April 29 webinar for FREE:
https://globalmeet.webcasts.com/starthere.jsp?ei=1757445&tp_key=0e7f653cd1

Music Credits:
Groovy 90s Hip Hop Acid Jazz by Musinova - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:24 | Sponsor message Copic medical liability insurance.

0:24 – 0:42 | Cold open Tolliver previews the episode's central warning: revenue leakage is a serious threat to financial stability — and it becomes more dangerous the more common it gets.

0:42 – 1:59 | Introduction Austin Littrell introduces the episode, plugs the April 29 AI webinar sponsored by Heidi Health and previews the conversation with Tolliver.

1:59 – 4:42 | What a strategic revenue cycle work plan actually looks like Tolliver explains how a strategic work plan aligns revenue cycle priorities with the overall business plan — broken down by quarter — and why most practices are still running off a business plan that hasn't been updated in years.

4:42 – 7:32 | Three moves to make in 30 days when payer friction is out of control Tolliver's framework: understand your denial drivers by volume, dollars and complexity; find where your cash is getting stuck in the AR aging buckets; and build real payer escalation relationships before you need them.

7:32 – 9:36 | The biggest mistake practices make when engaging payers Tolliver says it's showing up frustrated instead of prepared. Data, examples, trends and documented reference numbers beat complaints every time — because payers respond to evidence, not emotion.

9:36 – 12:08 | How to find the root cause when denials are spiking Tolliver's four-quadrant revenue cycle framework — front end, mid-cycle, payer communications and data — and how to use denial reason codes to trace a spike back to its source before it becomes a pattern.

12:08 – 14:02 | The denial type practices keep getting that a workflow fix could prevent Tolliver points to CPT coding as the most persistent offender — specifically the gap between correct coding initiatives and individual payer reimbursement guidelines — and explains why a payer-specific workflow is the fix.

14:02 – 18:00 | What a strong payer-specific action plan looks like — and who owns it Tolliver argues the billing team isn't the only one responsible. Providers, front desk staff and medical assistants all have a role — from closing notes on time to verifying benefits the EHR can't fully capture for certain specialties.

18:00 – 19:10 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

19:10 – 23:14 | Which metrics predict cash flow — and which create a false sense of security Tolliver's real cash flow predictors: aging AR, time-of-service collections, clean claims rate and denial rates by dollar amount. Her false sense of security warnings: gross collection rate and total charges, both of which can mask serious AR problems.

23:14 – 26:46 | When to automate, when to outsource and when to hire Tolliver's rule of thumb: automate anything repetitive, high-volume or rule-based; outsource when you need expertise you don't have in-house — like working down old AR during an EHR transition; and don't add staff until you've done a staffing ratio analysis.

26:46 – 28:42 | One tip to implement next week Tolliver's closing advice: look for revenue leakage. Under-coding, writing off collectible balances, accepting virtual credit card payments without negotiating rates and not pushing back on fee schedules are all quiet drains that practices normalize — and shouldn't.

28:42 – 30:40 | Outro Littrell thanks listeners, reminds the audience about the April 29 AI webinar and wraps the episode.

Ambient artificial intelligence (AI) scribes have become the fastest-adopted physician technology in recent memory. At UCSF, 70% of physicians now use one daily. At Kaiser Permanente, more than 7,000 physicians used them across 2.5 million patient encounters in just over a year. But what does the evidence actually show, and what are practices getting wrong?

In this feature episode of Off the Chart, Medical Economics Associate Editor Austin Littrell goes deeper on the AI scribe era, alongside Medical Economics' March-April 2026 cover story: Take note: The AI scribe era is here.

Robert Wachter, M.D., chair of the Department of Medicine at UCSF and author of "A Giant Leap: How AI Is Transforming Healthcare and What That Means for Our Future," is our main guide — explaining why documentation was the right entry point for AI in medicine, why the efficiency gains have been overstated, and why he's worried about what happens at note number 50.

We also hear from Shannon Sims, M.D., Ph.D., FAMIA, of Vizient on the case for thinking beyond the 12-month P&L, Marc Succi, M.D., of Mass General Brigham on where AI clinical reasoning actually stands today, and health care attorney Dan Silverboard, J.D., of Holland & Knight on the legal risks practices can't afford to ignore.

Music Credits:
Silent Tension by AudioAmbi - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:24 | Sponsor message Copic medical liability insurance.

0:24 – 1:55 | Cold open and introduction Austin Littrell opens with the story of pajama time, introduces Dr. Robert Wachter and previews the episode.

1:55 – 5:00 | How we got here — and why documentation won Wachter explains what the EHR did to the clinical note, how generative AI scribes are different from older voice-to-text tools, and why documentation — not diagnosis — was the right entry point for AI in medicine. The driverless car analogy.

5:00 – 8:20 | What the research actually shows Adoption numbers at UCSF. Findings from the UCLA randomized trial in NEJM AI and the Mass General Brigham/Emory burnout study. Wachter on why time savings have been overstated — and why the real ROI is in retention, recruitment and joy in practice. Dr. Shannon Sims on thinking beyond the 12-month P&L.

8:20 – 9:19 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

9:19 – 11:30 | Where the tools fall short The 70% error rate finding. Wachter on the 50th note problem and the cognitive trade-off of no longer writing your own notes. Dr. Marc Succi on where AI belongs right now — and where it doesn't.

11:30 – 15:45 | The legal picture Dan Silverboard on physician liability, the three questions to ask before signing any vendor contract, HIPAA complications around AI training on patient data, and why 85% of health care AI investment going to startups should give practices pause.

15:45 – 17:47 | What to do right now — and what comes next Practical steps: know your tool, talk to your patients, review your notes, get your governance in order. Wachter on why AI scribes are singles — and what the home run looks like.

17:47 – 18:55 | Outro Littrell thanks the experts, points listeners to the cover story at MedicalEconomics.com and wraps the episode.

A new Medical Group Management Association (MGMA) report found that 95% of practices say administrative and regulatory burden has increased over the past several years. Anders Gilberg, MGMA's senior vice president of government affairs, says the data tells a clear story about why.

In this episode, Gilberg joins Physicians Practice Managing Editor Keith Reynolds, to walk through the biggest drivers, from the explosive growth of Medicare Advantage and its abusive prior authorization tactics to the persistent failure of the MIPS-to-APM transition that was supposed to have happened a decade ago. He explains why practices are now staffing three or more full-time administrative employees per physician just to manage payer requirements, and why a full quarter of all U.S. health care spending goes toward administrative burden, higher than anywhere else in the free world. 

Music Credits:
Healing breeze by Cephas - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:22 | Sponsor message Copic medical liability insurance.

0:22 – 0:44 | Cold open Gilberg previews the episode's central stat: a full quarter of all U.S. health care spending goes toward administrative burden — higher than anywhere else in the free world.

0:44 – 1:40 | Introduction Austin Littrell introduces the episode and previews the conversation with Gilberg.

1:40 – 3:01 | Setting the stage: 95% Gilberg explains the MGMA regulatory burden report and confirms the headline finding: 95% of member practices say administrative and regulatory burden has increased in recent years.

3:01 – 5:07 | What's driving the surge Gilberg traces the growth of Medicare Advantage — now covering over half of all Medicare beneficiaries — as the primary culprit, bringing commercial insurer frustrations into what used to be a simpler government program. He also flags the 90% of practices reporting increased prior authorization burden and the two-thirds still stuck in MIPS with no viable alternative.

5:07 – 7:07 | Is Medicare Advantage broken? Gilberg draws a distinction between Medicare Advantage as a model — which can enable innovative, patient-friendly care — and the commercial administration of Medicare Advantage, which has brought take-it-or-leave-it contracting, utilization review abuse, denials and audits to the top of MGMA's burden survey.

7:07 – 9:13 | What prior authorization actually looks like day to day Gilberg describes the real-world experience: delayed authorizations, denials, phone calls with clinicians who don't match the requesting specialty, and a patchwork of dozens of separate insurer portals — each with its own workflow — that practices must navigate simultaneously. He notes CMS is moving toward standardization, but the problem is nowhere near resolved.

9:13 – 11:00 | The cost in dollars and staff Gilberg puts a number on the problem: upward of three full-time administrative staff per physician, devoted entirely to prior authorization, audits and billing — while a full quarter of all U.S. health care spending goes to administrative overhead, the highest of any country in the free world.

11:00 – 12:20 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

12:20 – 13:56 | The WISeR model: a foot in the door Gilberg explains why the WISeR model — which introduces prior authorization into traditional Medicare across six states and 17 services — is alarming even for practices not yet affected. He notes the irony that CMS is simultaneously pushing for prior authorization standardization while rolling out WISeR on a separate, non-standardized portal. The concern: a slippery slope toward broader expansion.

13:56 – 15:54 | Why practices are still stuck in MIPS Gilberg explains the original promise of MIPS — a bridge to alternative payment models — and why it failed. Over a decade later, not a single APM has been produced by the Physician Technical Advisory Committee, leaving the vast majority of practices trapped in a reporting exercise that doesn't function as a meaningful quality improvement program.

15:54 – 17:33 | Burnout, access and the human cost 77% of MGMA members link regulatory burden directly to burnout. Gilberg explains what that means in practice: physicians retiring early, leaving rural communities, or moving into employed roles to escape the paperwork — leaving patients without access to care that can't easily be replaced.

17:33 – 19:19 | If Congress could do one thing Gilberg's answer: physician payment reform. Specifically, eliminating the tournament model from MIPS — which requires some physicians to be cut in order to fund quality bonuses for others — and aligning Medicare payment with inflation. He calls it an oldie but goodie that the system can no longer afford to delay.

19:19 – 20:50 | Closing remarks and outro Gilberg closes with a note of cautious optimism — hoping for progress on prior authorization and payment reform by year's end. Littrell thanks listeners and reminds the audience to subscribe and visit MedicalEconomics.com and PhysiciansPractice.com.

Artificial intelligence (AI) tools are proliferating fast in health care, but the legal framework around them is still catching up.

In this episode, Dan Silverboard, J.D., a health care attorney at Holland & Knight, joins Medical Economics Managing Editor Todd Shryock to explain how AI is currently being regulated — by states primarily, and by the FDA only indirectly — and where the biggest liability gaps exist for physicians and practices. He walks through what happens legally when an AI-generated recommendation contributes to patient harm, why the responsibility almost always lands on the provider, and why there is no get-out-of-jail-free card when an AI tool generates a higher billing code than what was actually performed. 

Music Credits:
Sky Drifter by Cephas - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:25 | Sponsor message Copic medical liability insurance.

0:25 – 0:51 | Cold open Silverboard delivers the episode's central warning: periodic auditing of AI-generated billing documentation is non-negotiable, and there is no get-out-of-jail-free card when an AI tool recommends a higher code than what was performed.

0:51 – 1:53 | Introduction Austin Littrell introduces the episode and previews the conversation with Silverboard.

1:53 – 3:09 | How AI in health care is currently being regulated Silverboard explains that states are the primary regulators, treating AI as a technology that supports clinical decision-making rather than a medical device. The FDA regulates AI only indirectly, based on whether it's incorporated into a regulated medical device.

3:09 – 4:57 | The two biggest liability risks for physicians using AI Silverboard identifies the core risks: 85% of health care AI investment is going to startups without proven compliance track records, and providers who blindly sign off on AI recommendations — clinical or documentation-based — without verifying accuracy are taking on serious legal exposure.

4:57 – 6:45 | Who is liable when AI contributes to patient harm Silverboard explains that legally, the provider must sign off on any AI recommendation, making them the primary responsible party. Technology vendors can face liability if their product is found to be wholly deficient — trained on biased or false data, for example — but broad liability disclaimers in vendor contracts make that a high bar.

6:45 – 7:28 | Should physicians document AI use in the medical record Silverboard says yes — physicians should document whether AI was used, whether they followed its recommendations and, if they deviated from them, why. Several states, including North Carolina, have already passed legislation or board guidance requiring exactly this.

7:28 – 8:37 | Compliance and billing risks from administrative AI tools Silverboard is direct: providers attest to the accuracy of their claims, and that responsibility doesn't transfer to an AI tool. Up-coding, down-coding and unbundling errors generated by AI are still the provider's problem. Periodic auditing and monitoring of all billing documentation — AI-generated or not — is essential.

8:37 – 9:27 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

9:27 – 10:36 | What to demand in an AI vendor contract Silverboard outlines the must-haves: robust HIPAA compliance representations and warranties, ongoing validation and bias testing with reporting obligations, and a data governance plan confirming the AI system and its training data are free from bias or untrustworthy sources.

10:36 – 12:30 | Privacy complications when AI learns from patient data Silverboard explains a key HIPAA limitation: vendors can only train on protected health information for the benefit of the contracting provider — not to improve their own product. De-identified data is simpler, but practices still need contract provisions prohibiting re-identification, which is an increasingly realistic risk as AI becomes more powerful.

12:30 – 13:24 | Legal concerns around ambient AI and automated note generation Silverboard says the core risk is providers relying too heavily on ambient AI without verifying that the record accurately reflects the encounter. Texas has already codified this as a statutory requirement for all providers using AI to record patient encounters.

13:24 – 15:13 | Three questions practices should ask before deploying AI Silverboard's framework: first, vet the vendor thoroughly for HIPAA compliance and a proven track record; second, understand your patient population's comfort level with AI, which should shape how and where you deploy it; and third, decide how you will disclose AI use to patients — regardless of whether your state requires it.

15:13 – 16:16 | Where AI-related litigation is heading Silverboard says if HHS projections hold, AI could actually reduce adverse events and litigation over time. But one area he expects to keep growing: lawsuits challenging health insurers' use of AI to deny or down-code claims and prior authorization requests.

16:16 – 17:15 | Closing thoughts and outro Silverboard closes with a note of optimism — AI holds great promise — paired with a practical bottom line: vet your vendors, monitor your billing, and build compliance checks into your program now. Littrell thanks listeners and reminds the audience to subscribe and visit MedicalEconomics.com and PhysiciansPractice.com.

Medicare's Wasteful and Inappropriate Service Reduction (WISeR) Model launched January 1, 2026, in six states, immediately drawing fire from physicians, patient advocates and members of Congress.

In this episode, Rep. Greg Landsman (D-Ohio), a co-sponsor of the Ban AI Denials in Medicare Act, explains why he believes the pilot needs to be stopped. He argues the model is less about reducing waste and more about using artificial intelligence (AI) to deny claims faster, at the expense of seniors — he points out that the entire program operates as a black box, with no transparency about how it works, why the six states were selected or how the financial incentives are structured.

Music Credits:
Rooftops by Buurd - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:28 | Sponsor message Copic medical liability insurance.

0:28 – 1:02 | Cold open Landsman previews the episode's central argument: human beings denying claims is already a problem — handing that job to a computer system that isn't learning, just denying faster, makes it worse.

1:02 – 1:59 | Introduction Austin Littrell introduces the episode and previews the conversation with Landsman.

1:59 – 3:29 | What the WISeR model actually does Landsman describes the model as the administration contracting with big tech to deny claims for seniors, starting with procedures they expect to be noncontroversial — specifically to normalize AI-driven claim denials.

3:29 – 5:05 | The Ban AI Denials in Medicare Act Landsman explains the bill would stop the pilot entirely, not just the prior authorization component. He argues it should attract bipartisan support — the target should be fraud, waste and abuse, not senior care.

5:05 – 6:06 | What physicians and patients are actually experiencing Landsman says the most common story he hears is a claim that got denied, then reversed on appeal because it was always medically necessary. His argument: that's where AI should be deployed — reducing wrongful denials, not speeding them up.

6:06 – 7:13 | The transparency problem Landsman says no provider he has spoken with understands how the model is being implemented or why these six states were selected. The financial incentives reward more denials, but the formula is unknown and the code is invisible — a black box with no accountability.

7:13 – 7:56 | Has any Medicare payment model ever been stopped by Congress retroactively? Landsman says he's not aware of one — and adds that the chaotic rollout of the WISeR model has compounded the underlying policy concerns.

7:56 – 8:44 | What prior authorization reform should actually look like Landsman calls for full transparency and a measurable reduction in wrongfully denied claims as the baseline expectation for any entity receiving public money.

8:44 – 9:36 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

9:36 – 11:35 | The fate of ACA premium tax credits Landsman says 22 million Americans rely on the ACA, and 32,000 of his own constituents needed the extension to pass. He calls on the Senate to act, warning that failure to extend the credits will cause real harm — and that people will die. He frames it as a political loser for Republicans who try to block it.

11:35 – 12:42 | Common ground 2025: key provisions Landsman highlights the ACA subsidy extension and PBM reform as the plan's most important pieces, arguing that pharmacy benefit managers are charging enormous markups and those savings need to reach patients.

12:42 – 13:22 | Medicare physician fee schedule Landsman acknowledges he wasn't focused on that specific piece of the plan, but says the broader point is clear: physicians aren't getting paid what they need to be paid, and it's causing serious problems across the health care system.

13:22 – 14:24 | A message to primary care physicians Landsman closes with a direct message to physicians: he's a huge supporter, he recognizes they're being asked to do more under greater pressure for less pay, and he wants them to know they have allies in Congress.

14:24 – 15:30 | Outro Payerchin closes the interview. Littrell thanks listeners and reminds the audience to subscribe and visit MedicalEconomics.com and PhysiciansPractice.com.

CMS's latest antifraud actions — withholding Medicaid funds from Minnesota, freezing enrollment for certain durable medical equipment suppliers and launching the CRUSH initiative — signal a broader shift in how the federal government plans to police health care fraud. In this episode, Pat Naples, J.D., senior associate at ArentFox Schiff, walks through the legal authority behind each of those actions and explains what the move from "pay and chase" to AI-driven real-time fraud detection means for physician practices. 

Naples covers what rights physicians actually have when payments are flagged or withheld, why CMS has near-total immunity even if an AI system makes a mistake, and why the Minnesota action is a warning shot for state-level enforcement everywhere. He also lays out a practical compliance roadmap for small practices without dedicated staff.

Music Credits:
Midnight Serenade by MORRIX Holyhold - stock.adobe.com
A Textbook Example by Skip Peck - stock.adobe.com

Editor's note: Episode timestamps and transcript produced using AI tools.

0:00 – 0:25 | Sponsor message Copic Medical Liability Insurance.

0:25 – 0:46 | Cold open Naples previews the episode's bottom line: health care fraud enforcement is not going away, and providers need to be vigilant on the front end.

0:46 – 1:42 | Introduction Austin Littrell introduces the episode and previews the conversation with Naples.

1:42 – 2:43 | Meet Pat Naples and ArentFox Schiff Naples describes his practice — health care fraud enforcement, compliance and managed care litigation — and ArentFox Schiff's national footprint.

2:43 – 5:52 | The legal basis behind CMS's three-part crackdown Naples walks through the distinct legal authority behind each action: the Social Security Act for the Minnesota funding withholding, the Affordable Care Act for the DME enrollment moratorium, and broad government rulemaking authority for the CRUSH request for information. He explains how the moratorium and CRUSH initiative work in tandem — one freezing new enrollment, the other seeking longer-term solutions.

5:52 – 7:17 | Legal guardrails on AI-driven fraud detection Naples identifies the two primary guardrails on the "detect and deploy" approach: a credible allegation of fraud must exist before funds are withheld, and CMS must follow procedural notice requirements. He notes that both are largely within the agency's own discretion in practice.

7:17 – 9:00 | Can an AI flag alone justify withholding payment? Naples explains that claims data mining has been part of federal health care regulations since 2011 — this isn't new. He says regulators typically look for large outliers across the data set, not single anomalous claims, though circumstances and provider profile both factor in.

9:00 – 12:13 | What physicians can do when payments are withheld Naples walks through the appeals path: a written rebuttal statement, then administrative review, then judicial review — a process he acknowledges can be slow. He stresses that providers should be monitoring their own claims data proactively, and that voluntary self-disclosure under the new policy can reduce penalties significantly if issues are caught early.

12:13 – 13:02 | P2 Management Minute Keith Reynolds shares practice management tips and invites listeners to submit their own workflow ideas.

13:02 – 14:48 | What the Minnesota action signals for other states Naples says the federal government's message is clear: states that aren't sufficiently vigilant about fraud will face intervention. He expects a meaningful uptick in state-level enforcement activity, pointing to Texas Attorney General Ken Paxton's aggressive pursuit of pharmaceutical companies as an early indicator.

14:48 – 17:35 | What the DME moratorium means for referring physicians Naples advises practices that refer patients to DME suppliers to scrutinize those relationships now — ensuring referral agreements fall within CMS safe harbors. Even practices that aren't targets of an investigation can be pulled in as witnesses, which requires responding to subpoenas, producing documents and making staff available for interviews.

17:35 – 18:39 | Other enforcement developments to watch Naples flags three: DOJ's new uniform corporate enforcement policy, a new joint HHS-OIG-DOJ task force, and the creation of a National Fraud Enforcement Division — all signals of increased focus and resources devoted to fraud, waste and abuse.

18:39 – 22:17 | Compliance risks that keep coming up at small practices Naples identifies the three most common compliance vulnerabilities: referral relationships and Anti-Kickback Statute exposure, documentation gaps around medical necessity, and inadequate cybersecurity resources. He notes HIPAA compliance has grown more complicated as cyber threats have multiplied.

22:17 – 23:48 | A compliance roadmap for practices without dedicated staff Naples outlines four practical steps: identify your high-risk areas first; implement proper training, including onboarding and annual compliance education; conduct basic monitoring of referral relationships and billing; and build a relationship with outside counsel or compliance consultants before an enforcement action forces the issue.

23:48 – 25:40 | Telehealth scrutiny and the big picture Naples closes with a warning about rising telehealth enforcement activity stemming from pandemic-era proliferation. He also pushes back on the idea that this is something new — health care fraud enforcement has been escalating consistently across administrations, and that trend is not going to change.

25:40 – 26:40 | Outro Littrell thanks listeners and reminds the audience to subscribe and visit MedicalEconomics.com and PhysiciansPractice.com.