The countdown to October 1 has already begun.

In this episode of the Practice Perfect Podcast, Jennifer McNamara and Maya Turner discuss why healthcare organizations shouldn't wait until implementation day to prepare for the FY2027 ICD-10-CM diagnosis code updates.

From documentation changes and coding revisions to compliance risks and provider education, this conversation focuses on practical steps every organization can take now to ensure a smooth transition. Whether you're a coder, auditor, provider, CDI specialist, or revenue cycle leader, this episode will help you prepare your team before the annual code update takes effect.

Jennifer and Maya also share implementation strategies, common pitfalls they see during ICD-10 transitions, and recommendations for educating providers before October Why early preparation matters for ICD-10 implementationarrives.

Jennifer McNamara, CCS, CPC, CDEO, CRC, CPMA, COSC, CGSC, COPC, CPCI
CEO & Founder, Healthcare Inspired LLC

Jennifer is a nationally recognized healthcare consultant, educator, author, and speaker with more than 20 years of experience in medical coding, auditing, compliance, documentation improvement, and revenue cycle management. She is passionate about helping healthcare organizations improve compliance while simplifying complex coding and regulatory changes.

Maya Turner, CPC, CPCO, CPMA, CPC-I, CFPC, CRC
Director of Auditing, Healthcare Inspired LLC

Maya is a nationally recognized coding, auditing, and compliance expert with more than 30 years of healthcare experience. As an AAPC Approved Instructor, consultant, and national speaker, she specializes in coding compliance, audit methodology, provider education, quality assurance, and operational excellence. Maya is known for translating complex coding guidance into practical strategies healthcare professionals can apply immediately.

🌐 Healthcare Inspired LLC: https://healthcareinspiredllc.com
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Jennifer McNamara and Maya Turner dive deep into the Office of Inspector General's (OIG) February 2024 guidance on Medicare Advantage compliance, focusing on network adequacy and access to care. This episode unpacks the hidden compliance risks that medical practices and Medicare Advantage organizations face, exploring the tension between gatekeeping policies, utilization management, and patients' right to timely access to medically necessary care. The hosts discuss systemic failures in prior authorization processes, outdated policies, and the role of artificial intelligence in claims processing—offering practical insights for healthcare practices navigating these complex regulations.

Network Adequacy & Access to Care

• The disconnect between provider directories and actual participation status
• Real-world patient scenarios: arriving at offices only to find providers no longer participate
• The gatekeeper model in Medicare HMO plans vs. traditional Medicare
• CMS regulations on network adequacy testing and the 2030 deadline
• Shared responsibility between insurers and medical practices for accurate information

Provider Education & Communication Gaps

• Lack of education from Medicare Advantage plans to providers
• Shift from in-person representative visits to electronic-only communication
• Conflicting guidance between state payers and Medicare managed care programs
• The need for clear, consistent communication about covered services

Utilization Management & Prior Authorization Issues

• Prior authorization as a core barrier to access to care
• Gatekeeping policies preventing medically necessary procedures
• Documentation's critical role in authorization decisions
• Importance of providers thoroughly understanding their contracts
• Peer review challenges: Not all "peers" are true specialists in relevant fields
• The problem of apples-to-apples comparisons (e.g., cardiologist vs. interventional cardiologist)

Policy Review & Compliance Risks

• Insurance companies operating with outdated policies (sometimes 5+ years old)
• Annual CPT code changes not reflected in insurer policies
• Compliance risk when policies aren't aligned with Medicare updates
• Many practices still lack comprehensive compliance plans
• The need for regulatory requirements to match current medical practice and technology

Automation vs. Augmentation in Claims Processing

• Differences between automation and augmentation in AI-driven systems
• Algorithm failures: Same claims denied incorrectly multiple times
• Automation doesn't guarantee accuracy or faster processing
• Predictive AI limitations in managing complex, multi-system healthcare plans
• The imperfect system behind the "perfect idea"
• Cost containment driving automation at the expense of quality

Contract Negotiations & Fighting Back

• Why some large healthcare systems write off millions instead of appealing denials
• Importance of having healthcare attorneys review contracts
• Real-world examples of providers who fought back successfully
• Balancing "getting business" with understanding contractual rights
• The financial benefit of appeals and proper reimbursement pursuit

OIG Oversight Areas (Preview of Future Episodes)

• Improper financial incentives and behind-the-books arrangements
• Marketing practices under scrutiny
• Risk adjustment methodologies
• Quality of care validation mechanisms

Topics for Future Episodes: Risk adjustment methodologies, quality of care oversight, and deeper analysis of OIG regulatory framework for Medicare Advantage organizations

Upcoming Events:

• General Surgery & Gastroenterology Combined Conference: June 4–5, 2026
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• E&M Symposium: Fall 2026

In this episode, Jennifer and Maya unpack the “Mean Girl Effect” at work — the subtle, strategic behaviors that create confusion, undermine credibility, and erode psychological safety without ever appearing overtly aggressive.

From social exclusion and information control to polite denial and professional gaslighting, they explore how toxic dynamics operate beneath the surface — and why high-performing, ethical professionals are often the most impacted.

You’ll learn:

• What the Mean Girl Effect actually looks like in real workplaces

• The psychology behind gaslighting and why it escalates near accountability

• How subtle manipulation destabilizes confidence and increases stress

• Why your nervous system reacts before your logic does

• Practical strategies to protect your clarity, credibility, and mental health

In the Eye on Healthcare Business segment, Jennifer and Maya provide a deep dive into the OIG’s updated Medicare Advantage Compliance Program Guidance — including key risk areas such as risk adjustment, marketing and enrollment, vendor oversight, and documentation expectations. They also discuss what increased enforcement activity from Attorneys General means for healthcare organizations today.

This episode is about naming patterns, protecting integrity, and understanding how culture, compliance, and credibility intersect.

OIG Medicare Advantage Industry Segment-Specific Compliance Program Guidance:

🔗 https://oig.hhs.gov/compliance/ma-icpg/