CodaHx Blog
Notes on claims, coverage, and cost.
Practical writing on claims auditing, pharmacy pricing, and payment integrity for self-funded employers.
- Claims IntegrityJun 9, 20265 min read
DRG Upcoding: How Severity Coding Inflates Inpatient Claims
Inpatient stays are paid by DRG, and a single severity code can move a claim into a higher-paying tier. Here's how that happens, why automated adjudication often misses it, and what a documentation-based audit looks for.
- Cost ContainmentMar 16, 20265 min read
PBM Reform Is Here: What Self-Funded Employers Must Do Before 2029
The CAA 2026, FTC enforcement actions, and new DOL disclosure rules are converging to reshape pharmacy benefits. Here's what self-funded employers need to audit, renegotiate, and document before penalties kick in.
- Claims IntegrityMar 10, 20265 min read
The Data Fragmentation Problem: Why Most Claims AI Stalls at Pilot
63% of healthcare organizations have deployed AI, but only 8% operate at enterprise scale. The gap isn't model quality — it's fragmented data. Here's what separates pilot-stage AI from production-grade claims intelligence.
- Cost ContainmentFeb 10, 20265 min read
Rising Costs and the Case for Data-Driven Risk Management
Healthcare costs are rising at a 15-year high. Here's why predictive analytics and real-time high-cost forecasting have become essential for self-funded employers.
- Cost ContainmentJan 20, 20265 min read
The 2026 Price Transparency Rules: What Self-Funded Employers Need to Know
CMS is tightening hospital price transparency enforcement in 2026. Here's what changed, why it matters for self-funded plans, and how to turn public data into savings.
- Claims IntegrityDec 15, 20254 min read
AI in Claims Processing: Moving Beyond Simple Automation
The claims software market is approaching $47B, but most solutions still rely on opaque models. Here's why governance-first, explainable AI is the future of claims integrity.
- Cost ContainmentNov 20, 20255 min read
Coding Errors and Contract Drift: The Quiet Tax on Self-Insured Plans
How much do miscoded claims, bundling misses, and contract drift really cost a self-insured plan—and where to recover dollars fast.
- AffordabilityNov 10, 20255 min read
Charity Care and Financial Assistance: The Savings Most Plans Miss
Section 501(r) discounts and hospital financial assistance can shave thousands off high-cost cases—if you screen early.
- Claims IntegrityNov 1, 20256 min read
The Medical Billing Error Playbook: Duplicates, Upcoding, and Drift
A practical guide for self-insured employers to catch billing errors before payment—without slowing TPAs down.
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