The Downgrade Era: How Payers Are Changing the Game with (My) Richelle Marting

Payers are constantly shifting tactics to find new and creative ways to do their favorite thing: Not pay claims. And if you can’t deny? Downgrade! We’re seeing a lot of new patterns and tactics on this front, especially on the Medicare Advantage/private payer side of the house. And so it was time to take a look at where we are on the state of denials, with just the right person: Richelle Marting of Marting Law, LLC. Richelle has guested on OTR twice previously, the last time in January 2025. I’m bringing her back for the trifecta to discuss: What’s new in the life of Richelle Marting—and at the law firm? Many few faces in the last 12 months... The denials landscape, including the tactical shift from hard denials to softer downgrades. Specific examples including Aetna Level of Severity Policy, Blue Cross and Cigna E/M downgrades Short-stay and readmission audits from MA plans: Does the 2-Midnight Rule apply to Medicare Advantage and one critical difference you need to know about. Other trends Richelle is seeing including sepsis, respiratory failure, and the use of artificial intelligence Successful appeals and prevention strategies Life on the speaking circuit, Richelle’s OTR Spotify playlist selection, and Guns N’ Roses “My Michelle” serendipity...