Health Care News:
 CMS Announces Manufacturer Participation in Second Cycle of Medicare Drug Price Negotiation
The Centers for Medicare & Medicaid Services announced that agreements have been signed with manufacturers of the 15 drugs covered under Medicare Part D. These include diabetes and obesity drugs, drugs used to treat asthma and chronic obstructive pulmonary disease, type 2 diabetes, different types of cancer, and other medical conditions. Learn more.
 Healthcare Supply Chain, Pharmacy Costs to Rise in 2025
Health supply chain costs and pharmaceutical expenses are projected to rise modestly between July 2025 and June 2026, according to new research. Supply chain costs will rise by approximately 2% during the period, following higher prices for raw materials, increased freight and shipping costs and tariffs on medical-surgical products, according to the report. Read more.
 New FDA Policies Could Limit the Full Value of AI in Medicine
The implementation of AI in medicine is advancing rapidly. Some experts predict that within the next few years, developers may achieve artificial general intelligence (AGI), a groundbreaking form of AI that can understand, learn, and apply knowledge across various tasks with nearly human-like proficiency. This new technology could effectively synthesize vast amounts of clinical data regarding a patient’s condition and interpret complex medical issues. Learn more.
 National Nurses Week
May 6-12, 2025!
Join us as we honor the invaluable contributions of nurses worldwide and their unwavering commitment to patients, communities, and our health care system.
CME / CE Spotlight Course – Complimentary for ABQAURP Diplomates through May 29, 2025!
 Fuel Your Success with the Power of Happiness
Harjot Singh, MD
Leadership Consultant - HarjotSinghMD.com and Faculty - American College of Healthcare Executives
This one-hour audio online course teaches learners to employ happiness activities to promote leadership strength, prevent burnout, and foster the well-being of the health care team.
How joyfully do you live and savor your life? Practice happiness and tap your hidden potential for success. The dangerous myth: "If you become successful, you'll be happy." The wholesome truth: "Being happy fuels more success." With just one hour of training, you will put yourself in the race to the top - be seen as a likable and lovable leader by others. Practice happiness and tap your hidden potential for success. Make a leap into joy and achievement so others would want to follow you. Let this virtuous cycle of happiness and success be a part of your life forever!
At the conclusion of this activity, members of the interprofessional team should be able to better:
- Discuss how cultural myths of happiness are causing harm to the well-being of the health care team.
- Determine how to integrate evidence-based well-being activities into your routine to prevent clinician burnout.
- Employ happiness and well-being goals to provide leadership within your organization or group.
Access CME / CE Spotlight Course HERE.
*Price will automatically update in your cart to no charge when ordering online. Spotlight course is also available to non-members at the regular price.
The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
ABQAURP designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1 contact hour through the Florida Board of Nursing, Provider # 50-94.
Optimizing Utilization Management: Aligning Industry Regulations, Capturing Earned Revenue and Streamlining Workflows
 Dr. Timothy Brundage, CCDS
CEO and Physician Advisor, Brundage Group
It was once believed that healthcare was recession proof. Most healthcare executives know all too well that is no longer the truth. Healthcare is still trying to rebound from the COVID pandemic, but higher labor and supply costs are likely to continue to outpace reimbursement rates. As it becomes increasingly difficult for hospitals to grow their way out of declining operating margins, many executives are seeking ways to capture earned revenue. Engaging with experienced Physician Advisors who understand the nuances of the hospital clinical revenue cycle can improve the efficiency and accuracy of patient status determinations, ultimately strengthening financial performance and supporting optimal utilization review (UR) processes.
Observation: A Blind Spot for Utilization Review (UR) Efforts
The management of observation patients is often overlooked by utilization management workflows, leading to revenue leakage. Unfortunately, many UR departments use a one-size-fits-all screening process that ignores the Medicare Two-Midnight Rule by relying upon commercial screening criteria when validating patient status for Medicare beneficiaries rather than how long the patient will or has received hospital services and physician judgement. Partnering with experienced Physician Advisors helps ensure alignment with regulatory guidelines and enables hospitals to capture the revenue they have rightfully earned.
The codification of the Two-Midnight Rule in 2024 as the basis of inpatient medical necessity determinations for Managed Medicare beneficiaries is a gamechanger as more and more Medicare beneficiaries enroll in Medicare Advantage (MA). Data indicates MA enrollment has increased by at least seven percent in each of the last six years and surpassed those with traditional Medicare beginning in 2023 (MedPAC, 2024).
Observation and Medicare Advantage
MA plans have been slow to adopt the Two-Midnight Rule. The November 2024 Revenue Cycle KPI Benchmarking Quarterly Report from Kodiak found a significant difference in observation rates between traditional Medicare and those with MA plans even though the same medical necessity criteria apply to both populations. As the MA population grows, hospitals cannot afford to be paid observation services rates for Medicare patients who likely meet criteria for inpatient hospitalization. Depending on the hospital’s base rate, the difference between reimbursement for observations services and an inpatient admission can be several thousand dollars per patient.
Streamlining Workflows
When payors use time-based medical necessity criteria, it allows some functions previously performed by hospital UR staff to be automated. This is particularly important when managing Medicare observation patients because the time they are receiving hospital services is tracked in hours. Hospitals should be actively monitoring how long Medicare patients receive observation care.
- Medicare requires a minimum of eight hours to bill Medicare Part B for observation.
- Observation stays longer than 24 hours result in revenue leakage based upon how it is reimbursed by Medicare.
- Traditional Medicare patients who are expected to need hospital care beyond two midnights should be converted to inpatient status as soon as the expectation is met.
Why Actional Metrics for Utilization Review Matters
Perhaps one reason so many MA patients are billed as observation is a climate of denial avoidance. Unfortunately, too many hospital executives implement goals to reduce the volume of denials rather than tracking how hospital UR functions contribute to denial volumes. Many hospitals have become overly conservative with their patient status determinations to avoid denials, which are increasing despite these efforts. Hospital leadership needs to be monitoring the final denial rate rather than the initial denial rate. The February 2025 Revenue Cycle KPI benchmarking quarterly report from Kodiak found an initial denial rate of 11.8% with a 2.8% final denial rate in 2024 suggesting that appealing denials works.
While there is a cost associated with appealing inpatient authorization denials, leveraging Physician Advisors during the peer-to-peer process generates savings that offset the investment. Incorporating the Physician Advisor into the Medicare self-denial review process supports revenue capture for the care already delivered - using physician judgement that commercial screening tools simply cannot replicate.
Conclusion
Failure to address gaps or inefficiencies in hospital UR processes results in revenue leakage. While validating inpatient admission orders is critical, it often takes precedence over monitoring patients placed in observation. To capture earned revenue for the care already delivered, hospitals must proactively track observation rates across both traditional Medicare and MA, as well as length of time receiving observation services.
 Learn more about “Utilization Management, Industry Regulations, Revenue Leakage and Workflow Inefficiency” during Dr. Timothy Brundage’s session at the ABQAURP Annual Conference on Friday, September 12, 2025.
For more information and to register, visit: www.abqaurp.org/AnnualConference.
REFERENCES
Kodiak. (Feb. 2025). “February 2025 Revenue Cycle KPI Benchmarking Quarterly Report.”https://www.kodiaksolutions.io/internal/benchmarking_reports/kpi_
benchmarking_february_quarterly
Kodiak. (Nov. 2024). “November 2024 Revenue Cycle KPI Benchmarking Quarterly Report.” https://www.kodiaksolutions.io/internal/benchmarking_reports/kpi_
benchmarking_november_quarterly
The Medicare Payment Advisory Commission. (July 2024). “A Data Book: Health Care Spending and the Medicare Program." https://www.medpac.gov/wp-content/uploads/
2024/07/July2024_MedPAC_DataBook_SEC.pdf
Registration is Open to Attend ABQAURP's 2025 Annual Conference
ABQAURP's 48th Annual Conference offers attendees the opportunity to learn about the latest trends in the health care quality and patient safety industry.
Join us September 11-12, 2025, at the Sheraton Sand Key Resort in Clearwater Beach, FL, as we discuss, “Partnering for Success: Quality-Focused Collaboration in Health Care.”
Attain Current and Topical Information!
Stay Ahead of the Curve! Bring back the knowledge and skills to adapt to sweeping changes in the health care landscape. Boost your expertise with our education! The result will be more proficient and expedited care, allowing for a better, safer health experience for both patients and providers.
Earn Valuable Continuing Education Credits!
Maintain your certification and ensure you are expanding your knowledge about important topics that are shaping our way of healing every day. ABQAURP’s conference offers specialized and current education about important factors in today's health care field. Members of the interprofessional health care team earn CME/CE in content areas that are valuable to you.
Connect with the Field!
Interact with your peers and our industry-leading faculty at events planned to encourage networking like the reception and during meals. Gain perspective and learn valuable first-hand experiences as this specialized group of interdisciplinary team members impart their successes and failures, allowing you to take back an arsenal of information to implement at your workplace.
Refer a Colleague!
Do you know a colleague that would benefit from ABQAURP education or membership? Invite them to our conference to discover our top-notch education! You will receive 50% off your registration fee when one non-member colleague attends conference. Your registration is free when two non-member colleagues attend conference!
View tentative agenda and register HERE.
Sheraton Sand Key Resort
 
Make your hotel reservations online here or by calling Reservations at (727) 595-1611. Identify yourself as an ABQAURP attendee to receive our special room rate of $219/single or double occupancy, by August 15, 2025. Rooms in this block are limited and are on a first-come, first-served basis.
Complimentary Online Courses!
 ABQAURP provides the highest standard of accredited CME/CE. View a list of complimentary online courses in the Center for Continuing Education.
These courses are available to non-members – no promo code required!
View complimentary online courses HERE.
Membership Dues Reminder - Don't Walk Away from Quality – Pay Your Dues Online
 If you have not done so already, please pay your member dues online now! ABQAURP is grateful for your membership and ongoing support of our shared goal to improve the quality of health care provided to patients. We recommend paying your membership dues online through our secure payment system.
If you have any questions or need assistance, please contact Membership Services at (800) 998-6030. ABQAURP does not engage in lobbying; 0% of your membership dues are allocated for lobbying activities.
Pay your dues online HERE.
Attention Diplomates - Recertification Reminder
Attention Diplomates! Recertify now and avoid delays! We recommend completing your recertification early in your cycle instead of waiting until the deadline to recertify.
CHCQM Recertification: Complete a minimum of eight (8) CME / CE credit hours of applicable continuing education every two years and remain current with all account balances. Read the HCQM Recertification Policy.
CPHYADV Recertification: Complete a minimum of 20 CME / CE credit hours of continuing education as relevant to the field of Physician Advisory per two-year recertification cycle and remain current with all account balances. Read the CPHYADV Recertification Policy.
ABQAURP’s Center for Education provides high-quality educational activities including ABQAURP’s Annual Conferences on-demand, complimentary courses and more! Learn new skills and strategies from the comfort and convenience of your own home or office.
Applicable online course credits automatically apply toward Diplomate recertification or certification exam eligibility requirements.
Promote your ABQAURP certifications with digital badges. Earning Health Care Quality Management (HCQM) and/or Advanced Physician Advisor (PHYADV) certifications validates your expertise and helps you to stand out amongst your peers as a leader.
Share your accomplishments with a digital badge on your LinkedIn profile, Facebook page, on your website, or email signature. Each badge contains verified metadata describing your qualifications and the process to earn them. Click the badge to verify ABQAURP credential and the issue and expiration dates.
The secure digital format displays credentials in real-time and eliminates the step to request verification from ABQAURP. Digital badges allow easy sharing with employers and peers. Digital badge credentials are also available for Sub-Specialty Certifications.
Claim digital badge HERE.
View a compiled list of organizations that recognize, prefer, or require HCQM Certification and/or Advanced Physician Advisor Certification when seeking new employees.
Earn the credential of Certified Advanced Physician Advisor – CPHYADV!
Applications are currently being accepted for the Advanced Physician Advisor exam, and the testing window is open! Submit your application now to reserve your preferred test time and location.
Download the handbook and apply HERE.
Health Care Quality Management (HCQM) Certification Exam
Apply today for the Health Care Quality and Management Certification exam. Applications are currently being accepted, and the test window is open. Submit your application now to secure your preferred testing time and location.
Download the handbook and apply HERE.
HCQM Sub-Specialty Certifications
Validate your specialized knowledge and experience through HCQM sub-specialty certification. Sub-specialty certification may be applied for during completion of the initial HCQM Exam application, or you may return and apply after passing the HCQM Exam and achieving Diplomate status.
Sub-Specialty Certifications are available in the following categories:
- Case Management – CHCQM-CM
- Managed Care – CHCQM-MC
- Patient Safety/Risk Management – CHCQM-PSRM
- Physician Advisor (US-licensed physicians only) – CHCQM-PHYADV®
- Transitions of Care – CHCQM-TOC
- Workers' Compensation – CHCQM-WC
Prepare for the Health Care Quality and Management (HCQM) Certification Exam
Prepare to become a quality leader or refresh your knowledge by completing the HCQM: A Review of the Core Body of Knowledge® (CBK) online course. This course is a primer for the Health Care Quality and Management Certification Exam.
Learn the basics of health care quality, risk management, accreditation, and patient safety. With ABQAURP’s CBK online course, you can prepare for the exam on your own terms and at your own pace.
View details and order course HERE.
ABQAURP's Center for Continuing Education
 ABQAURP’s Center for Education provides high-quality educational activities including ABQAURP’s Annual Conferences on-demand, complimentary courses and more! Learn new skills and strategies from the comfort and convenience of your own home or office.
Applicable online course credits automatically apply toward Diplomate recertification or certification exam eligibility requirements.
Browse catalog HERE.
Join ABQAURP as a Professional Member! Membership is open to all health care professionals, including those in clinical and health care managerial roles.
Be recognized for your commitment to quality health care! ABQAURP has led the health care quality movement for over 48 years and has grown to become a premier professional association providing board certification in Health Care Quality & Management (HCQM) and Advanced Physician Advisor Certifications, ACCME-accredited continuing medical education, and membership to health care professionals worldwide. View a compiled list of organizations that recognize, prefer, or require HCQM Certification and/org Advanced Physician Advisor Certification when seeking new employees.
Professional Membership benefits include:
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