We need a “human in the loop” in mid-revenue cycle work, experts say. 

What they fail to answer is the more interesting question:  

Where in the loop, exactly?

Back-end AI fact-checker? Front-end query authorizer? Or, maybe something like my current OTR guest Penny Jefferson envisions: Medical record maestro. 

The end-to-end connectedness of the medical record, evolving API standards, increased use of prior authorization, episode-based reimbursement models, and review of all of this by AI and other tools makes documentation cohesion more important than ever.  

CDI is changing with the times, but often not fast enough. It must change, or risk stagnation and possible extinction. The ready availability of vast amounts of information in the EHR and AI-enabled reviews and audits means a slip in a diagnosis can result in a big DRG downgrade or denial of stay altogether. 

But an AI powered enabled CDI maestro conducting the show can make a record strong, front to back. 

Penny has been writing like a fiend about many of these and other related topics for LinkedIn and the likes of ICD-10 Monitor--which is what led her back to the hot seat of the Off the Record studio. Listen in as we discuss: 

• A day in the life of: Penny’s evolving role at UCDavis 

• Her take on today’s CDI work, where is it coming up short and/or at risk of being automated away? 

• UR function/medical necessity and how CDI can assist case management without igniting a turf war. 

• “Longitudinal episode integrity”: Episode-based bundled payments (TEAM, etc.) and how they shift chart review beyond discrete diagnosis review to breadth 

• APIs and FHIR standards: Issues with fields that don’t match throughout the medical record leading to denials, bringing it home with an encephalopathy example 

• Where does CDI need to upskill to meet these new demands? Does the “traditional” chart review/query role need to change ... or do we need an entirely new role to evolve to meet these demands? And what about productivity metrics? 

• Addressing the elephant in the room. Where is the human in the loop? For example: should a human review every AI query before it goes out? Spend more time on high dollar, 5+ day stays? Tiebreak a co-equal dx? 

• Updates on admit type. Listeners might recall our previous show on this topic, with  loose NUBC definitions leading to urgent vs. elective categorization to minimize impact on quality metrics. 

• Other fun stuff you only get on #OTR 

Payers are constantly shifting tactics to find new and creative ways to do their favorite thing: Not pay claims. And if you can’t deny? Downgrade! 

We’re seeing a lot of new patterns and tactics on this front, especially on the Medicare Advantage/private payer side of the house. And so it was time to take a look at where we are on the state of denials, with just the right person: Richelle Marting of Marting Law, LLC. 

Richelle has guested on OTR twice previously, the last time in January 2025. I’m bringing her back for the trifecta to discuss: 

• What’s new in the life of Richelle Marting—and at the law firm? Many few faces in the last 12 months... 

• The denials landscape, including the tactical shift from hard denials to softer downgrades. 

• Specific examples including Aetna Level of Severity Policy, Blue Cross and Cigna E/M downgrades 

• Short-stay and readmission audits from MA plans: Does the 2-Midnight Rule apply to Medicare Advantage and one critical difference you need to know about. 

• Other trends Richelle is seeing including sepsis, respiratory failure, and the use of artificial intelligence 

• Successful appeals and prevention strategies 

• Life on the speaking circuit, Richelle’s OTR Spotify playlist selection, and Guns N’ Roses “My Michelle” serendipity... 

AI feels like a bubble. A bubble that keeps expanding until it fills the entire room—including the Off the Record podcast studio. 

I remain bullish about some aspects of this game-changing technology and intensely skeptical of others. Which makes it a fascinating topic. Worthy of a fascinating guest, who not only has opinions but has real-world applications for the tech you might not have thought of. 

Sharon Easterling has a towering, all-consuming passion for AI, specifically bridging the gap between technology and the mid-revenue cycle and navigating a technological future that can seem overwhelming. But she also leans into its creativity. She even sent me a new OTR podcast jingle created with AI! You can hear it on this episode. 

Listen in as we discuss: 

• Who is Sharon Easterling, “Fractional AI Governance and Enablement Executive | AI and Digital Transformation Leader”? 

• Are we lost in the wild west of AI? Coders are using ChatGPT to code and pass certification exams, and employers screening employees with AI bots.  

• How much has AI actually penetrated the mid-revenue cycle, use-wise? Can ChatGPT code? Will AI applications replace people? 

• Where AI ais ctually making a tangible difference in the mid-revenue cycle: Denials management, surfacing diagnostic indicators, writing appeals letters, and more 

• Some out-of-the-box suggestions of using AI in your daily workflow: From monitoring coding productivity to sending daily education to your inbox. 

• How Sharon thinks people should view AI more broadly. 

Referenced on the show: Sharon’s article “The Medical Record: How Artificial Intelligence (AI) Impacts Coding”:  https://icd10monitor.medlearn.com/the-medical-record-how-artificial-intelligence-aiimpacts-coding/  

In a day and age where we’re too often looking in the mirror and focused on our own problems and successes, Tiara Minor is all about empowering others.

As the Director of CDI for University of Miami Health system Tiara makes things happen for her team, because she’s all about sharing her expertise and education, growing her staff, and now the CDI profession itself. She’s giving back on the broader stage as an ACDIS advisory board member, conference speaker, and now biggest achievement—guest on Off the Record.

(I wrote that last one with a straight face, barely).

One of the things that impressed me about Tiara was her observation that most training seems to be geared for CDI leaders. Her focus is on her staff, making sure that they have not just mastered the fundamentals of chart review, but also clinical nuances across service lines.

We get into education, mentorship, and more on today’s episode. Listen in as we cover:

• Tiara’s broad responsibilities and a typical day in the life
• System focus, CDI metrics, and dashboard
• Her nontraditional journey into CDI--ER nurse to pediatrics, a foray into consulting, and return to the hospital setting. And winning over some skeptical coders along the way...
• Mentorship: Growing her staff and how she differentiates mentorship that from management.
• Her role as educator and an example of an interesting clinical query/quality opportunity she presented to the team
• An ACDIS splash—getting elected to the advisory board, winning both an individual award (recognition of professional achievement) and an organizational award (Diversity in CDI), and the speaking circuit.

This year has been something of a reckoning for Medicare Advantage. Senator Grassley’s scathing report of UHG’s risk adjustment practices, and the Kaiser $556 million settlement to resolve False Claims Act allegations of upcoding, opened eyes, and got many in the industry talking.

I wanted to get someone on the show with opinions, unafraid to speak their mind and share their perspective.

I’ve found that person.

Betty Stump is Senior Solution Consultant for Edifecs, a Cotiviti Business. She is in the business of risk adjustment and value-based care on the vendor side, but is never afraid to offer her opinion on the industry, pro and con. And with more than 20 years in the industry across multiple well-known companies, it’s an informed one.

Listen in as we discuss:

• What is working in value-based care/risk adjustment—and where have we gone wrong? Recent conference disillusionment.
• Kaiser DOJ fine and the Grassley report taking aim at UHG’s aggressive risk adjustment strategy: Betty’s thoughts and where does this heightened era of scrutiny put risk adjustment coders. Do we need to elevate the MEAT standard?
• What are organizations missing with risk adjustment?
• Great, practical, low-tech suggestions for RAF capture including using your 2025 end-of-year roster to identify those patients with high-risk conditions and engage in proactive outreach to get patients seen.
• V28 of CMS-HCCs with V24 in the rear-view mirror.
• Truthful tech talk: How leaders can get a seat at the table, how to get a vendor’s ear to modify functionality, and truth and hype in CDI tech
• How should a CDI or coder interact with a machine prompt from a suspecting tool?
• Looking back at a colorful 20-year career in the consulting life, and a thoughtful selection for the Off the Record Spotify playlist by a fellow music enthusiast.

Medicare Advantage is undergoing a reckoning ... and that reckoning is coming from within. 

In January Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that it violated the False Claims Act by submitting invalid diagnosis codes for their MA Plan enrollees in order to receive higher payments from the government.  

The case was instigated by what is known as whistleblowers. 

Regular listeners might recall my podcast on this topic back in January 2025 with Mary Inman, a Partner at Whistleblower Partners LLP, and Head of International Whistleblower Practice for the firm. We had a fascinating conversation about the process of whistleblowing and New York insurer Independent Health, which agreed in December 2024 to pay $100M to settle allegations it had upcoded claims to inflate MA payment. 

We’ve now more than 5x-ed that fine with Kaiser. Per the Department of Justice the claims resolved by the settlement are allegations only and there has been no determination of liability. But it was a major wakeup call for MA. 

Mary is back for today’s show along with her colleague Liz Soltan, a senior associate in the firm’s NYC office. Listen in as we discuss: 

• Key terms: What is whistleblowing and the concept of qui-tam? 

• Kaiser case origins which began more than 12 years ago, and Mary and Liz’s evolving roles in the case 

• The facts on the ground, as alleged by the whistleblowers and the DOJ, specifically the issue of addenda to the medical record 

• Unfolding of the case, a behind the scenes look as new whistleblowers joined, and reaching of the settlement 

• What can we learn from a medical coding/reimbursement perspective? 

• What can healthcare organizations do to ensure their employees don’t blow the whistle and avoid similar fines and headlines? 

I’m consistently surprised at how few CDI or IP coding professionals talk about their most basic job function. The very reason they are hired, and what most do for eight hours a day:

I'm talking about chart review.

Go on Linkedin or Facebook and it’s rarely discussed.

Yet it’s ... everything. Nuanced, complex, clinical, critical to the quality of financial health of hospitals. It’s how patient acuity is expressed in coded data, how hospitals get paid, and why CDI and coding professionals are employed.

I’ve heard it described as akin to detective work, puzzling together the pieces and presenting an informed query to the provider. Yet like detective work it often remains a mystery.

Dr. Tarman Aziz joined me to open up that conversation. He is founder and CEO of CDIQ Consulting, LLC, a physician-led healthcare education and consulting firm focused on closing the gap between clinical reality and coded data. On this episode of #OTR we discuss:

• Is chart review unique to the individual/healthcare organization/assistive tech, or are there underlying principles everyone can follow?
• How evolving clinical indicators in a case drive a concurrent CDI workflow—the differences of reviewing a chart at 24 vs 72 hours as clinical indicators morph
• How early is too early to look at an inpatient chart?
• Underutilized and underrated areas of the health record
• Review strategies for encephalopathy, dehydration, hyper- and hyponatremia, and cerebral edema/compression
• Tarman’s work consulting and educating non-traditional CDI candidates
• The remarkable story of Tarman’s fiancé Anna, an 11-year survivor of Stage 4 breast cancer

And we’re off! The first episode of #OTR of 2026, From Risk to Revenue Clarity: How One Health System Transformed OP CDI Performance.

I continue to beat the drum of outpatient CDI because I believe in it.

Risk adjustment and capitated payments are a superior reimbursement mechanism than fee-for-service. Certainly not perfect, but I believe they are better aligned with keeping patients healthy.

It’s also an exciting new avenue for CDI and coding professionals to work.

Making it work isn’t easy. Success requires new workflows, new metrics, and an even greater level of physician education/buy-in than acute care settings.

We get into all of this on today’s show.

My guest Jason Jobes, SVP of Norwood Solutions, is a whiz when it comes to value-based care, you will be hard-pressed to find a more informed speaker.

Note: You can download the slides referenced on the show here, though they are not needed.

Here we are, our last episode of Off the Record this year. 

I hope you’ve had a great 2025. 

Just my voice today. 

I’m ending with a solocast, a reading/summary of a paper about the biggest news story of the year: The explosive growth and proliferation of artificial intelligence, or AI.  

You might recall my poll from a couple weeks ago; you all confirmed it. 

Where do people fit with this tech? None of us really know, but I offer my opinion here. 

Outpatient CDI is still in its pioneer-”ish” stage. Why do I say that? Per the most recent ACDIS survey data, only 31% of respondents indicated their organization had a dedicated OP CDI program.  

Progress, but not enough, and still a minority. 

So when you find an “OG” who has been working in risk adjustment for well over a decade, you need to pay attention. Odds are they’ve got some lessons to share and wisdom to confer. That certainly describes Amy Campbell, Director of Outpatient CDI for LifePoint Health.  

Listen in as we discuss:  

• “Building the airplane as we were flying...” Her start and early days in OP CDI. 

• A “day in the life of” her role as OP CDI Director today for a large and growing healthcare organization 

• Dashboard for success and most impactful/important KPIs 

• Manual chart reviews (yes, they do this—no assistive tech). What does a pre-visit review look like/how is it conducted, and what common clarifications and dx opportunities are her team finding? 

• Rapid fire round: Biggest OP CDI pet peeve (a doozy), RN vs. HIM staffing decisions, and the hardest part of managing people 

• Interesting career stops, from critical care nurse and neurological intensive care nurse, to consulting, to content reviewer for Lippincott. 

• Being a mother of an adult child with autism