Question 1

What is OptimIQ Health?

Accepted Answer

OptimIQ Health is a healthcare revenue cycle and risk adjustment company. It offers one subscription platform covering patient engagement, eligibility, visit preparation, care management, coding, revenue cycle, and risk adjustment on a single record, and managed services run by its own team: CPMA-certified audits, revenue cycle management, eligibility verification, medical coding, billing and AR, value-based care and risk adjustment, practice analytics and consulting, and clinic website design. It works inside the EHR a practice already uses, and a person reviews every finding before anything is filed.

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Question 2

Why do medical claims get denied?

Accepted Answer

In Experian Health’s State of Claims 2025 survey of revenue cycle leaders, the most common causes were missing or inaccurate claim data (50 percent), authorizations (35 percent), and incomplete or inaccurate patient registration data (32 percent). 41 percent of providers reported denial rates of 10 percent or higher. Most of these causes can be caught before the claim is sent, which is why coverage, benefits, and authorizations are checked before the visit. (Source: Experian Health, State of Claims 2025.)

Question 3

What are the prior authorization deadlines in 2026?

Accepted Answer

Under the CMS Interoperability and Prior Authorization final rule (CMS-0057-F), starting January 1, 2026, Medicare Advantage organizations and Medicaid and CHIP programs, including their managed care plans, must decide expedited prior authorization requests within 72 hours and standard requests within 7 calendar days, and give a specific reason when they deny one. The prior authorization APIs the rule requires are due January 1, 2027. (Source: CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).)

Question 4

How often does CMS audit Medicare Advantage risk adjustment?

Accepted Answer

In May 2025 CMS announced it would audit every eligible Medicare Advantage contract each year through Risk Adjustment Data Validation (RADV), about 550 contracts, sampling between 35 and 200 records per contract, and would work through payment years 2018 to 2024 on an accelerated schedule. It also said it would grow its medical coder workforce from about 40 to about 2,000. Every submitted HCC needs documentation in the record that supports it. (Source: CMS RADV announcement, May 21, 2025.)

Question 5

Is CMS-HCC V28 fully in effect?

Accepted Answer

Yes. Payment year 2026 is the first year Medicare Advantage risk scores are calculated entirely under V28, after a phase-in of 33 percent in 2024 and 67 percent in 2025. V28 pays on 115 HCCs against 86 in V24, and 7,770 risk-adjusting ICD-10-CM codes against 9,797. Many related conditions inside a disease family now share one coefficient, and a number of codes that paid under V24 no longer map to any HCC. Specific, supported documentation matters more than it did. (Source: CMS CY2024 Rate Announcement; CY2026 risk adjustment implementation.)

Question 6

What does MEAT actually require?

Accepted Answer

MEAT stands for Monitor, Evaluate, Assess or Address, and Treat. Reviewers look for at least one of the four documented at a face-to-face encounter before they accept a condition as supported. It is an industry review convention, not a federal rule; the official ICD-10-CM guidelines still govern. A condition carried only on a problem list, with no sign it was addressed, is what fails a chart review. (Source: ICD-10-CM Official Guidelines; common risk adjustment review practice.)

Question 7

What does chronic care management require each month?

Accepted Answer

CPT 99490 covers at least 20 minutes of non-face-to-face clinical staff time in a calendar month for a patient with two or more chronic conditions expected to last at least twelve months, under general supervision, with consent documented. CPT 99439 adds each further 20 minutes, up to twice. The same practitioner cannot report it in the same month as complex CCM (99487) or physician-time CCM (99491) for that patient. (Source: AMA CPT 2026; CMS Chronic Care Management Services guide.)

Question 8

What changed for remote patient monitoring in 2026?

Accepted Answer

The device thresholds split. CPT 99454 still requires 16 or more days of transmitted data in 30 days, and new CPT 99445 covers 2 to 15 days at the same 2026 payment rate. Only one of the two can be billed for the same 30 days. Management time splits the same way: 99457 remains the first 20 minutes in a calendar month, and new CPT 99470 covers 10 to 19 minutes. The two are not billed together. Setup under 99453 now expects at least 2 days of data. (Source: CMS CY2026 Physician Fee Schedule final rule; AMA CPT 2026.)

Question 9

How tight is the transitional care management window?

Accepted Answer

Interactive contact has to happen within 2 business days of discharge. The face-to-face visit has to happen within 14 calendar days for CPT 99495, or 7 calendar days for 99496 where medical decision making is high. The service period runs 30 days from the date of discharge, and only one provider may report it for that discharge. (Source: AMA CPT 2026; CMS Transitional Care Management Services guide.)

Question 10

When is principal care management the right program instead of CCM?

Accepted Answer

Principal care management covers a single complex condition expected to last at least three months, where chronic care management requires two or more. It is billed in 30-minute monthly increments: CPT 99424 and 99425 for physician or qualified health professional time, 99426 and 99427 for clinical staff time. The same practitioner cannot bill it in the same calendar month as CCM for that patient, but it can run alongside remote monitoring. (Source: AMA CPT 2026; CMS Care Management Services guidance.)

Question 11

What has to be in an annual wellness visit?

Accepted Answer

G0438 is the initial visit, once per lifetime and only after twelve months on Part B; G0439 is each subsequent visit, once at least 11 full months have passed since the last one. Both require a health risk assessment, medical and family history, a list of current providers and suppliers, height, weight, body mass index and blood pressure, cognitive and functional screening including fall risk, and a written personalized prevention plan. It is not a routine physical, and the separate Welcome to Medicare visit is G0402. (Source: CMS Medicare Learning Network: Annual Wellness Visit.)

Question 12

How often does the ICD-10-CM code set change?

Accepted Answer

Every year, on October 1. The FY2026 update took effect on October 1, 2025 with 487 new codes, 38 revisions, and 28 deletions. A code that was correct last year can be wrong this year, so coding checks need to run against the current code set. (Source: CMS FY2026 ICD-10-CM code update files.)

Question 13

Does OptimIQ replace our existing systems?

Accepted Answer

No. The platform reads the record you already keep and writes back into it. Nothing is submitted from a finding on its own. A person reviews every one, accepts or rejects it, and the accepted evidence lands in the chart with the sentence that supports it. (Source: Product design constraint.)

Provider	Focus	Finding	Action
Provider A	E/M levels	Undercoded 99213	MDM education
Provider B	Modifier 25	Unsupported	Corrective plan
Provider C	HCC support	Supported	Re-audit in six months

Confirmed. Covered. Documented. Coded. Paid. Defended.

Most lost revenue is decided before a claim goes out.

From a booked visit to a claim that holds up.

Every patient, on one screen.

Checked before the visit. Paid after it.

Patient intake.

Coverage and authorizations

Coding and charges

Denials and AR

Risk scores that hold up in an audit.

Sentence-level evidence

MEAT validation

Signed & attested

One-click RADV packet

Before the visit

Coded with evidence

Audit ready

Know where you stand every month.

Monthly report

CPMA-certified audits

Consulting

Measured against your numbers, not an average.

Baseline

Connect

Run

Review

For the people who deliver care, and the ones who pay for it.

Clinics

Texas FQHCs and RHCs

Home Health Agencies

Hospitals

Health plans

ACOs

RCM companies

Works beside the EHR you already pay for.

EHR & technology integrations

API-friendly architecture

Clearinghouse & payer connectivity

Workflow automation & agents

Voice agents

Straight answers, with a source for each.