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

No matter how great your CDI program is—its spectacular workflow, outstanding chart review team, on-point KPIs, shiny new AI tools—nothing works if you don’t have engaged physicians.

It still all comes down to provider engagement. Without a physician staff who is bought in and willing to participate and document with specificity in the health record, all these efforts are for naught.

But with great engagement, great things are possible.

So where are we today with the big daddy of all CDI topics? Joining me on this episode of #OTR are two physicians with considerable experience and plenty of war stories. Trey LaCharite, Medical Director for CDI and Coding and Clinical Associate Professor for University of Tennessee Medical Center, and Vaughn Matacale, director of the physician advisor group for ECU Health in North Carolina, open up for a frank, no-holds barred discussion on the following topics:

• What is overrated when it comes to provider engagement--and what is underrated?

• The best high-tech solution each recommends, and a great low-tech solution that stands the test of time.

• An ultimate success story winning over a difficult provider or service line.

• Notable failures others can learn from.

• RUSH reunion tour in 2026—yay or nay? Spoiler alert: Of course the answer is yes...

• And other fun stuff you really shouldn't miss...

Fans of Off the Record may recall my recent episode with Chris Petrilli, Director of Revenue Cycle of Operations at NYU Langone, who joined me to discuss his experience delivering a TEDx Talk on artificial intelligence.

Chris was well prepared and delivered a great lecture, which you should definitely check out on YouTube. And on the podcast he sang the praises of a coach brought in to prep him and other NYU Langone staff for the big day on the big stage.

My wheels started to spin, I reached out... and landed that coach for OTR.

Susanna Baddiel is an actress, director, voice over artist and TEDx Speaker Coach. She works in both the UK and the US and is a founder member of Actors Shakespeare Company where she continues to act, direct and coach. She has more than 17 years of experience teaching public speaking, personal impact, presentation skills, leadership development, and executive coaching.

It was my honor to host her in a bit of an offbeat show than the usual mid-revenue cycle topics. But I picked up a few pointers about public speaking that helped me, and I think you will too.

This special episode kicks off November, a month in which I’ll be taking a deep delve into provider engagement. Odds are if you’re trying to engage providers you’ll have to present or educate, and Susanna offers some great advice and practical tips and takeaways.

On this show we cover:

• Her background as an actress in Britain, transition into coaching, and eventually working with niche clients in science and medicine

• Working with the team at NYU and Chris Petrilli—preparing them, building them up, and getting them ready for the big day.

• Why preparation is everything in public speaking, as is gratitude for the opportunity

• Balancing authenticity vs. general principles of good presentation

• The differences between in-person and presenting on camera. Susanna offers some GREAT suggestions for being better on Zoom.

• Books and other resources Susanna recommends