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