We all get excited—and rightfully so—at the rapid advance of clinical medicine. New treatments, therapies, and drugs save lives. But when you work in the revenue cycle, you know that payment mechanisms can significantly lag new technologies.

When codes don’t exist, or reimbursement is woefully inadequate, you have to take action. Petition, sometimes at the highest levels of government.

Jugna Shah is fighting for improved coverage and reimbursement for CAR-T and other cell and gene therapies, a trip that recently took her all the way to Capitol Hill. On this episode she talks about exciting work underway to improve healthcare accessibility and reimbursement, shaking hands with popular politicians, and of course some can’t miss documentation and coding tips.

On this show we cover:

• Jugna’s mission and the mission of Nimitt Consulting
• CAR-T and other cell and gene therapies: Current reimbursement mechanisms, insurance and coverage issues, and regulatory guidance
• Jugna’s advocacy efforts at the recent White House Cell and Gene Therapy Forum
• What came out of the Forum and what’s next given the recent change in administration
• What hospitals can do today to receive appropriate reimbursement for these life-saving therapies (she offers up some great advice on setting appropriate charges, citing the regulations)
• Where are we with drug administration (i.e., coding of injections/infusions)

We hear about lawsuits and false claims acts regularly, but did you know that many of these begin with someone working from inside the organization? Calling out bad behavior or noncompliance, sometimes again and again without being heard—before deciding to call on a third party for help?

You might have seen the recent headlines about New York insurer Independent Health, which agreed in December to pay $100M to settle allegations it had upcoded claims to inflate Medicare Advantage payment. But did you know the basis of the lawsuit was a whistleblower, and 12 years in the making?

My guest on Off the Record knows this very well. Mary Inman is a Partner at Whistleblower Partners LLP, and Head of International Whistleblower Practice for the firm. She also served as legal counsel in this very case.

I continue my “law and coding” start to 2025 with a fascinating guest and topic. On this show we discuss:

Who/what is a whistleblower, and the concept of qui tam

The mechanics/process of a whistleblower engaging a lawfirm: Are they working for their employer throughout reporting, discovery? Is gathering evidence to support their case without employer knowledge illegal?

What happens to a whistleblower who wins—or loses? How much can they stand to make, and is their career over?

New DOJ whistleblower project to encourage additional reporting

What some whistleblowers get wrong/false report or misunderstand

What hospitals/healthcare organizations can do to lessen the risk

Mary’s Off the Record Spotify playlist selection (I was disappointed it was not Judas Priest’s Breaking the Law)

Medicare Advantage. It’s everywhere you turn. From upcoding to denials, the huge and growing program—which now covers more lives than traditional Medicare, but is increasingly the target of local and federal scrutiny and a stream of endless OIG audit reports—seems to be in the news daily.

In a sea of online anger and noise, there’s a few voices of reason, reminding us about the regulations and guidelines and how MA should be conducting itself—at least in theory.

One such person is Richelle Marting. Richelle is an RHIA and a JD and owner of a host of coding credentials besides. As a Healthcare Reimbursement Attorney and Founder of Marting Law, LLC, she brings a unique legal viewpoint to medical coding, coverage, and payment. She knows what regulations bind Medicare Advantage plans—and how these are often skirted.

On this show we cover:

• Richelle’s start to 2025, personally and professionally

• What MA plans must cover and pay for, by law

• Prior authorization

• Under which circumstances MA plans can use internal coverage criteria

• How MA plans game the system: three sneaky tactics you won’t want to miss

• The latest on automated denials/use of AI

• Richelle’s answer to the question: Medicare Advantage: Yay or Nay?

• An interesting new year’s resolution and latest addition to the OTR Spotify playlist

Richelle’s desktop MA policy links:

Governing rules for Medicare Advantage: Code of Federal Regulations 42 Part 422: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C

Final rule for MA plans (April 2023), 4201-F: https://www.federalregister.gov/documents/2023/04/12/2023-07115/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program

Medicare Internet-Only Manuals: https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms

Medicare Advantage 2026 proposed rule: https://www.federalregister.gov/documents/2024/12/10/2024-27939/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare