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Varied Hot Topics for Hospital Compliance & Revenue Integrity issues,
pointing you in the direction of solutions.
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THIS WEEK ON FINALLY FRIDAY! LIVE
PAYER DENIALS
FROM HELL!
Three hospital nightmares you cannot make up.
Friday, October 30, 2026 • 1:00PM ET • Free live discussion
Medicare's AI-assisted prior authorization experiment. A new trauma charge edit that demands two paid items. An appeals graveyard where challenges rarely get filed. We will separate what the evidence actually says from what a scary headline seems to imply.
Three nightmares. Three different rulebooks.
Some rules change billing. Some change care. Some reveal what happens when nobody challenges a decision. They are not interchangeable.
1. The Authorization Phantom
New October 26 research found lower utilization of certain services after Medicare's WISeR prior authorization model began in six states. Was the care unnecessary, delayed, or both? The study does not answer that question - and its numbers are not denial rates.
2. The Payment-Edit Vampire
Aetna announced a January 1, 2027 trauma charge edit requiring a paid G0390 and a qualifying paid ambulance charge on the same service date. We will contrast that announcement with October's separate CMS trauma reporting clarification.
3. The Appeals Graveyard
Pennsylvania's October 27 individual-market insurance report shows fewer than 1% of denied items appealed by members. Those are not hospital appeal rates - but what does your own hospital's denial funnel look like?
What we'll work through together
Our invited discussion panel is expected to include Tiffany Ferguson, Dr. Deepak Pahuja, Dr. John Zelem and Glenn Krauss, with Ernie de los Santos moderating. Final lineup subject to availability.
- What the new WISeR study can - and cannot - tell us about prior authorization.
- How a trauma claim edit can change reimbursement review, and why payer-specific rules matter.
- A practical four-gate approach for deciding which denials to challenge.
- One measurable action to take back to work on Monday.
Our format: 45 minutes of guided conversation + 15 minutes reserved for audience questions, clarification, and the inevitable great debate. Real sources. Constructive disagreements. A little Halloween humor.
For hospital utilization management, physician advisors, CDI, coding, revenue integrity, denials, appeals, and compliance teams.
Source documents
JAMA, Oct 26 | CMS WISeR | Aetna notice | CMS trauma update | PA Insurance Department
Educational discussion; not legal, medical, coverage, or claim-specific reimbursement advice. Halloween nicknames are humor, not findings of wrongdoing.
...In the immortal words of Rosanne Rosanadana...
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Ernie also produces and moderates another LIVE show, MONTHLY on Thursdays at https://physicianonline.org
THIS show is all Physician Advisors, and is mostly clinical topics, going over top disease specific concerns and questions. Free to watch live! Register Now!
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Core CDI offers several resources to help you address your Revenue Cycle and CDI needs. You can find Word documents, PowerPoints, videos, links and more that focus on the "How to" and "Why?" questions that invariably arise.
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Learn the Key Changes No Part of the Regulations, including Limits on Precedential Decisions, Attorney Adjudicators & CMS Contractors.
Free 1-hour webinar. Another exceptional presentation by Jessica Gustafson, a founding Partner at The Health Law Partners.
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