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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