AAHIM | Why the Payers are Winning and You’re Not

Learning to Play an Infinite Game vs. a Finite Game & Why That Matters

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How do you explain when all the money invested in CDI, Physician Advisors, Coding, Billing, Case Managers doesn’t show a real improvement in denials, appeals and write offs?

Many programs and tools being offered to hospitals today either fail to deliver as promised or fail to deliver solutions that work for very long. At least part of the reason for this has to do with what is expected of them, even before they are purchased and implemented.

We will explore what Game Theory can teach us about the Why and What is happening in so-called healthcare reform, and look at how to address the challenges present in value-based performance programs and overzealous efforts by third party payers to reduce their medical loss ratios and enhance their own profitability through engagement in medical necessity and clinical validation denials strategies. 

By attending this highly informative and thought-provoking session, participants will gain the practical mindset to recognize the strategies and tactics necessary to begin playing the same “game” and with the same rules being used by the payers, better insuring the survival of their facilities, their jobs, and sometimes even the lives of their patients.

Session Objectives:

  • Understand the differences between an Infinite versus Finite game, in Game Theory
  • Learn how and why to play an Infinite Game no matter your job or your title
  • Learn how “playing” by Finite Game rules makes it almost impossible to improve revenue integrity
  • Understand why, how and when you are in a Finite Game or an Infinite Game
  • Understand and learn how any process designed by the silo approach contributes to increasing costly self-inflicted issues; e.g., preventable denials
  • Learn to identify the values evident in decisions made by payers
  • Learn to identify the values evident in decisions made by hospitals (or even you)
  • Understand why some decisions made by you or others sometimes feel uncomfortable – which is not always a “bad” thing
  • Learn why the attitude of “fix it in the back end” is inherently and inevitably dangerous to the revenue cycle, your own job, and even patient care
  • Learn how Physician Advisor and CDI Programs can successfully play an Infinite Game, by adopting best practice standards and principles of documentation
  • Share successes as well as pitfalls to avoid in transitioning from the reactive concept of Denials Management to the proactive concept of Denials Avoidance
  • Identify and describe some of the Key Performance Indicators (KPIs) for Physician Advisor and CDI Programs that are appropriate measures for playing the Infinite Game
  • Create a personal vision and purpose for your own job – regardless of title or function – that drives a daily focus on improving patient-focused quality healthcare, anywhere.

Experience Level: Any

Date Published:

May 21, 2020


CEU: 1.0 – Data Structure, Content, and Information Governance


Ernie de los Santos

Ernie de los Santos is an optimist and author, Co-founder of the Non-Profit Top Gun Audit School, founder of Appeal Academy, Host and creator of Finally Friday! LIVE, and Executive Director of the Council for Certification of Medical Auditors, Inc. Ernie created Top Gun Audit School in early 2019 to promote his vision of a healthcare system where you can wake up every morning excited to go to work because you get to be part of helping people in need of healthcare, feel your job is secure, and go home fulfilled at the end of every day. He founded Appeal Academy and Finally Friday! LIVE in 2011; and continues to produce bi-weekly free webinars on process improvement and regulatory compliance – now numbering over 250 free webinars. Prior to entering the healthcare industry in 2006, he spent over 20 years in research and development of new business models and production processes, working on projects for Fortune 100 corporations, including Coca-Cola, Kodak, SONY, Panasonic, MCI, US Sprint and the International Olympic Committee. He holds degrees in Archaeology, Computer Science, and Marketing.

Glenn Krauss

Glenn Krauss is a well-recognized & respected subject matter expert in the revenue cycle with an emphasis & focus upon collaborating & working closely with physicians in promoting, advocating for, educating & achieving sustainable improvement in clinical documentation that accurately reflects & reports the communication of fully informed coordinated patient care.  He possesses 25 plus years of progressive practical hands on experience in clinical coding & documentation improvement, subscribing to the philosophy that quality of medical record documentation strongly correlates with overall quality of care & the overall achievement of a high performing revenue cycle. What sets Glenn apart in the clinical documentation improvement arena is the recognition of clinical documentation effectiveness, accuracy, completeness & contextual consistency as fundamentally integral with all components of the revenue cycle.


Members and Non-Members: $20


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Course Includes

  • 1 Lesson
  • Course Certificate