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

Here we are, at the end of the year. And the end of another season of Off the Record.

For reasons that will soon become clear, I wanted to wrap up 2024 by pushing myself out of my comfort zone. Because this episode is about personal growth.

So here I am, doing my first ever solocast.

I bring you the Top 5 lessons learned over the year of Off the Record. These apply to mid-revenue cycle leaders, our core audience for #OTR, but they’re broad enough for anyone to adopt.

This is a tidy episode, just 26 minutes of distilled wisdom from several guests that I was honored to host.

Enjoy, Merry Christmas and Happy Holidays, and I’ll see you in 2025.

Last month I wrote a post about the four stages of a career, using the analogy of seasons. I was inspired by the wonderful fall weather I was experiencing while on a walk here in New England, but also by changes I have been experiencing in my life and how these have caused me to re-evaluate what’s important in my career.

The post got a good reaction, including from Nicole Fox, Associate Chief Medical Officer, Medical Director of Pediatric Trauma, Medical Director of CDI, at Cooper University Health Care. Which led to this show.

Nicole and I are in the “fall-ish” of our careers. Which might sound like we’re getting ready for pasture, but not really. I’m 51 and Nicole is 48, so we have many more years to work—but our priorities are changing. You might say, they are better aligning with the new people we are becoming, as human works in progress.

Nicole has done a lot with career coaching, both as recipient and mentor, and we get into all that on today’s show—and bare our souls a little bit about what is holding us back.

This was a terrific conversation with an amazing person and I suspect you’ll enjoy it, and maybe come away a bit more reflective about your own career and priorities.

On this show we discuss:

• An update on Nicole’s work as a pediatric trauma surgeon and hospital executive—and the need for changes

• Her experience with a career coach and what she learned about herself

• Career “saboteurs”—how do you discover them, and what can you do to diminish them? I highly recommend taking the free assessment linked below (my top 3 saboteurs are avoider, hyper achiever, and pleaser)

• Is it possible to shape your career, and how does that look in practice?

• The “seasons” of a career and using it as a framework for discovering what is most important (with an emphasis on the fall season)

• Nicole’s forays into coaching and mentorship, and prioritizing health and work-life balance in a demanding clinical career

Show notes

• Four stages of a career: https://www.linkedin.com/posts/brian-murphy-13800b11_i-love-the-fall-especially-here-in-new-england-activity-7253050994937212932-2QFY?
• Career saboteurs assessment: https://www.positiveintelligence.com/saboteurs/

With 23 years and counting in CDI, Rhoda Chism has seen a lot. The rise of new regulations and reimbursement mechanisms, and the advent of new technologies that have radically transformed chart reviews.

Rhoda has not only weathered these changes and navigated the turbulent waters, but remains as warm and personable, and pro-person, as you will ever meet.

But not anti-technology.

Today she is the Director of Clinical Excellence and Adoption for the software company Iodine, a new position she’s held for just two months. But I think she could be called Chief People Officer. We get into the blending of human and machine, discussing the following:

• Rhoda’s journey into healthcare and nursing at the tender age of 19.

• The transition from bedside nursing to CDI in 2001

• Melissa Varnavas and the lasting impact of a simple message of encouragement and belief

• Using authentic, personal stories to communicate difficult CDI concepts and education, including heart failure and AKI

• How technology has radically transformed CDI over the last two decades

• AI driven technology as human amplifier, not replacement, and the importance of emotional intelligence in CDI work

• Career advice for young professionals in a world of rapid change

Karen Elmore is living in denial(s).

Her job as Senior Clinical Documentation Quality Coordinator for BJC Healthcare involves a daily battle against a never-ending tide: Payers denying diagnoses on the perceived basis of lack of clinical support. Recently she’s had to deal not only with human payers, but artificial intelligence denials as well.

Karen’s organization has worked hard to stem this never ending tide, and found some success with uniform organizational clinical guidelines and consistent education and engagement.

We talk denials, appeals, preventing future denials through provider education, and Kansas City Chiefs football (still undefeated as of publish date), on this episode of Off the Record.

On this show we cover:

• Karen’s unique role as program manager for CDI at BJC, including responsibilities for physician education, engagement, and denials prevention

• Typical denials for sepsis, respiratory failure, and malnutrition: What payers are using for ammunition

• What payers are the worst offenders, and particularly creative (and egregious) tactics

• AI denials—how do you spot them, and combat a machine?

• Provider engagement strategies and relaying denials back to physicians

• Legitimate reasons for denial and ongoing documentation shortfalls

• Karen’s Kansas City Chiefs obsession—inside an average Sunday in the Elmore household (it’s crazy)

Following is part 2 of our interview with Revka Stearns, who joined us on Off the Record to provide an update of her first eight months on the job as a new inpatient coder.

If you haven’t listened to part 1 I’d recommend starting there, since we pick up mid-conversation. On this show we cover:

• The mechanics of working as a remote coder. Workplace setup and helpful recommendations
• Dealing with the physical challenges of working at a desk all day and breaking up the routine
• Unexpected consulting work coming her way ... from Canada!
• Unfiltered conversation about social media. Revka’s take on the social media landscape, dealing with negativity, dispelling persistent myths (there’s no coding jobs! It’s all being outsourced! Yes there are, and not it isn't—Revka is proof), and being a consistent, positive, and helpful online presence.
• Keeping sane through work-life balance, and her latest Off the Record Spotify playlist entry