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Is Your AI Query Tool Compliant by Default?

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By BRIAN FENGLER

Every night in the emergency department, the electronic health record hums with small demands for attention. A nudge about sepsis. A best-practice advisory. A documentation suggestion that arrives between patients and asks for one more click.

Most of us treat those prompts as background noise. Almost none of us stop to ask whether a given nudge is, in fact, a query, or whether it was built to the same standard a clinical documentation specialist has to meet.

In August, that question got an official answer. And it is not the answer many health IT vendors have been selling.

The American Health Information Management Association and the Association of Clinical Documentation Integrity Specialists released the 2026 update to their Guidelines for Achieving a Compliant Query Practice, shaped by feedback from nearly 200 individuals and groups. The principle is plain: “Whether a query comes from a person or technology, the standard for compliance should remain the same.”

Then comes the sentence that should end a familiar sales claim: “Organizations should not assume that a vendor-supplied or EHR-integrated tool produces compliant queries by default.”

For years, “compliant by default” functioned as an unspoken promise around AI-enabled clinical documentation and utilization review tools.

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Discharge Planning Ends at the Funeral Home. That’s a Health System Failure.

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By EVAN REID

We reconcile medications at discharge because we decided, correctly, that the handoff out of a hospital is a clinical event with its own failure modes. Then a patient dies, and the same hospital that would not let them leave with an unreconciled med list hands the family a folder and a phone number for the funeral home.

Grief is separate, and the system is at least gesturing at that. What follows the folder is work. Months of it, procedural, deadline-bearing, and owned by nobody on the care team.

I run a consumer estate-settlement publisher, so I see the searches families make in the days after. They search for form MV-39. They search for whether they are allowed to use their father’s car, and for which county holds the hearing. They do unfamiliar administrative work at the worst cognitive moment of their lives, and they do it alone.

First, the objection

The reflexive answer: this is what a trust is for. It is a good objection and it fails on timing.

A trust is a pre-death instrument. The family standing in a corridor at 2am cannot act on it. Whatever should have happened in 2019 is off the table now, and an intervention available only years in advance answers nothing at the moment of discharge. Here is why that matters: the discharge desk is the last moment at which anyone official is still in the room.

The objection also concedes too much. A fully funded trust avoids probate. It does not touch death certificates, account closures, creditor notice, Social Security, final tax filings, or retitling a vehicle. Many trusts are only partly funded, so assets never retitled into the trust go through probate anyway, and families often learn this only after the death.

Take the car. Retitling a dead parent’s car means finding the right state form, the right affidavit, and an answer to whether anyone may use it in the meantime. No trust touches any of that. It is administrative sediment, identical for the well-planned estate and the unplanned one, and it lands on the family in week one.

So a trust changes who handles part of the work. The family still handles the rest.

What the burden actually is

Let’s break it down. Here is what nobody prices at discharge.

Court filing fees are the small part, a median of about $233 across the fifty states, ranging from $30 to $750, according to our 50-state probate cost study. That is the number people expect. The damage comes from attorney fees.

Only seven states set ordinary attorney fees by a statutory or presumed schedule. In the other 43, the price of settling an estate stays hard to know until the work is done. Lawyer billing rates have a median of about $312 an hour across the states, per Clio’s Legal Trends data. If a straightforward estate takes ten to twenty-five hours, which is our working estimate, that is roughly $3,100 to $7,800 before anything goes wrong.

Then there is the asset nobody can pause. Holding an inherited home costs a national median of $6,312 a year, or $526 every month, in property tax and insurance alone, before a mortgage payment, before utilities, before a roof. That figure ranges from $2,974 in West Virginia to $12,907 in Florida, per our carrying-cost study. The meter starts the day of the death and it does not care whether the family has letters yet.

The rules also change at the state line in ways nobody would guess. Nearly every state offers some small-estate shortcut around full probate, with thresholds from about $15,000 to $400,000 in Wyoming, and many of them cover personal property only. The same estate can be a short affidavit in one state and a court process in the state next door. Families do not know this. Why would they?

Why the hospital and not someone else

The usual reply: this is not clinical, so it is not ours.

We already accepted that discharge carries non-clinical obligations with clinical consequences. Medication reconciliation is not a treatment. Neither is confirming a patient has a ride home, or that the prescription is affordable. We do those because we recognized the handoff as the point where preventable harm concentrates.

Death is a discharge. It is the one discharge where the hospital holds complete information, a captive moment, and a documented point of contact, and it is the only one where we hand over nothing but a folder.

The counter-argument I take seriously is scope creep. Hospitals should not own every downstream social problem, and staff are not estate administrators. Agreed. So the ask should be small.

Next steps: the proposal

The ask is one checklist item.

At the point of death certification, the discharging hospital should hand over one state-specific sheet answering four questions. How many certified death certificates this state’s agencies will require, and where to order them. Whether this estate plausibly clears the state’s small-estate threshold. Which county court has jurisdiction. And the first filing deadline that exists in this state.

That is all. Four facts, one page, generated from the decedent’s state of residence, using information the hospital already holds. It is not legal advice, it creates no liability the hospital does not already carry, and it occupies the same slot in the workflow that medication reconciliation does.

The reason to do it: these four facts are cheap to supply and expensive to discover, and the cost of discovering them late falls on people we just finished caring for, at $526 a month, in a process where a missed deadline in an unfamiliar county court is an easy mistake to make.

We built a whole discipline around the idea that handoffs fail. Then we drew its boundary at the exact moment the patient stops being one.

Evan Reid is the founder of Settled Estate, a consumer estate-settlement resource covering probate procedure in 47 states. It is a publisher, not a law firm.

Health and Democracy on the Ballot: A Conversation with Dr. Atul Gawande

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I’m inviting you to a virtual Movement Voter Project event with Dr. Atul Gawande on Thursday, October 22, 8PM ET • 7 PM CT • 6 PM MT • 5 PM PT Register here

This virtual event is a Movement Voter PAC (MVPAC) fundraiser to help Movement Voter Project (MVP) provide critical funds and resources to grassroots organizations in red and purple states.  Right now, MVP partners are organizing voters in every winnable Senate race, in every contested House race. Funds donated now can fuel critical early voting and mail-in campaigns, integrate voter protection and election safety, and prepare rapid responses to threats and interference. This is a moment when our generous giving can make a crucial difference–Matthew Holt

Wall Street in the ER: How Private Equity Is Squeezing Local Hospitals

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By ADAM LEE

Reflecting on a Private Equity (PE) internship in New York City reveals a major takeaway: financial engineering can be incredibly empowering, but applying it to public infrastructure often catches vulnerable communities in the crossfire.

The PE industry typically views the world through balance sheets, debt structures, cash flow optimization, and lucrative acquisitions. While these principles generate immense profit on paper, applying them to local healthcare—specifically safety-net hospitals—creates severe real-world tradeoffs.

Here are the major takeaways regarding the intersection of healthcare and business.

1. How Hospitals Get Saddled with an LBO

In the PE world, a Leveraged Buyout (LBO) is the primary acquisition method. An LBO pushes the debt onto the acquired asset, similar to convincing a bank that a newly purchased home will pay off its own mortgage.

For hospitals, this process typically follows a specific pattern:

  • The PE firm borrows huge sums to purchase a hospital and its infrastructure.
  • That borrowed debt lands directly on the hospital’s balance sheet.
  • The firm sells the hospital’s land and buildings to a real estate company for quick cash.
  • The hospital is left paying rent (with built-in escalators) just to operate inside its own building via a sale-leaseback arrangement.

The clearest example is Steward Health Care.

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Healthcare Is Fighting the Wrong AI War

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By KIM BELLARD

The Blue Cross Blue Shield Association is crying wolf about AI. Its new analysis claims that “hospital systems are increasingly billing patient hospital stays as more medically complex,” and that these upcodings cost BCBS plans almost $1b from 2023 to 2025. That’s just claims from hospital systems, just to BCBS plans, so the total number could be much higher.

Well, you might say, a billion here, a billion there – that’s just healthcare these days. Everything is going up. But BCBSA is less sanguine; it thinks the coding is part of a strategy, and it thinks AI is driving that strategy.

“If patients are truly sicker, we’d expect to see more treatment,” said Luke Chalker, BCBSA’s senior vice president of product and data science. “For example, we’re seeing significantly more anemia diagnoses at these hospitals without a corresponding increase in transfusions. The disconnect between diagnoses and treatment suggests that AI is identifying more billable conditions, not sicker patients.”

The analysis indicated that most (70%) of the increased costs came from secondary diagnoses that shifted payment into higher reimbursement categories, so the hypothesis is plausible.

The American Hospital Association, of course, is having none of it. An August 2026 ”fact sheet” on AI and coding intensity called claims of AI driving coding intensity “unsubstantiated,” citing numerous factors that drive coding intensity. It blamed insurers for having AI-supported “downcoding programs,” the purpose of which are “to arbitrarily and inappropriately reduce provider reimbursement for medically necessary care that has already been delivered.”

AHA also snarkily but accurately noted how many Medicare Advantage plans have been caught upcoding members to boost their Medicare payments, so it depends on where one is sitting.

It’s also worth noting that this year the Trump Administration rolled out a Medicare program — Wasteful and Inappropriate Service Reduction (WISeR) – to use AI to help identify “fraud, waste and abuse” – a.k.a., deny claims. It has not, to say the least, gone well.

Both sides are using AI, to each other’s detriment. Which is to say, our detriment.

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Time to Stop “Calling it Reimbursement”

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By JEFF GOLDSMITH

Back during the Jurassic period, at the beginning of my consulting career, senior colleagues at Ernst and Whinney took me to lunch to explain to the newby the facts of life in healthcare finance. The biggest takeaway from that long ago conversation: the entire history of hospital finance was built up on the revenue side. Managing costs was simply too challenging for most C-suites, because it inevitably required involvement with medical staffs who, at the time, were independent practitioners and beyond the hospital’s direct control. Therefore, the job of payers-governments and private insurers- was to “reimburse” hospitals for their expenses (that is, so long as the costs were “allowable”). The subtext of using the term “reimbursement” was : “We already spent the money and you owe us!”

In 2026, this mindset miraculously persists. This is despite the fact that Medicare, the largest and most influential payor for hospital services, has not reimbursed hospitals for the cost of inpatient care for more than forty years and for outpatient services in more than twenty! And the rest of the payment system is rebelling against the role as the residual payer for the hospital’s “unreimbursed” expenses.

The result of three generations of managements trained to these expectations is akin to football players who only trained their upper bodies and left the lower bodies to nature. Catching the ball is one thing; blocking and tackling with no lower body leverage is quite another.

Today’s C-suites lack the reflexes, management information and cultural support to respond substantively to the damaging blow that is HR 1, which will both reduce dramatically Medicaid payment and increase the number of uninsured patients by as much as 14 million. Controlling expenses today means engaging clinicians-physicians and nurses-and altering their workflows, staffing and incomes, a political nightmare for many managements.

The “reimbursement” mindset is a huge handicap standing between current leadership and actual control over their operations. For those in an indefensible cost position, it is so much easier to give up ownership, merge with a larger system and let someone else unburdened by local socio-political constraints and perhaps with better management controls clean up their extensive agenda of unfinished business. The reluctance of legacy managements to actually cut costs is a hidden contributor to the industry’s continuing consolidation.

Those who pay for care have had enough. The ability of care system leaders to shift those unmanaged costs onto the dwindling collection of full bore commercial payers is coming to an end. Commercial insurers are no longer willing to fund all the hospitals “unreimbursed” costs. Angry progressive policymakers and academics, egged on by Arnold Ventures, are agitating in state legislatures to cap commercial rates as a percentage of Medicare.

Sooner or later, hospital managements will take ownership of their piece of the healthcare affordability challenge. And they will be getting up early to hit the gym . . . and build the strength, balance and muscle memory to manage their entire business, not just their revenues.

Jeff Goldsmith is a veteran health care futurist, President of Health Futures Inc and regular THCB Contributor. This comes from his personal substack.

The Rural Radiologist Who Already Exists

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By STEVEN GOODMAN

The future of rural healthcare won’t be determined by how much money is invested. It will be determined by how wisely that money is used.

That line gets nodded along to at every rural health conference, then quietly ignored the moment the conversation turns to solutions, because the solutions on offer are almost always capital solutions: build a wing, buy a scanner, recruit a specialist who will not, in fact, be recruited. I spent a career building infrastructure for GE Medical Systems, standing up systems for remote patient monitoring before “telehealth” was a word anyone used. The lesson that career taught me is one rural health policy still hasn’t absorbed: the expertise a small hospital needs is usually not missing. It’s just licensed in the wrong state.

The Equipment Isn’t the Bottleneck

Consider radiology, because it’s the clearest version of the problem. A critical access hospital in rural Wisconsin can afford a CT scanner. What it cannot afford, and cannot realistically recruit, is a subspecialist radiologist sitting in the building waiting to read scans that come in one or two at a time. That expertise exists — in large quantities, at hospitals and reading services in Chicago, Minneapolis, or Milwaukee, often sitting idle overnight.

The technology to connect the two has existed for two decades. A scan can move from a rural imaging suite to a subspecialist’s screen in seconds. What can’t move nearly as fast is the paperwork — and there’s more of it than most people outside a hospital credentialing office realize.

A radiologist licensed to practice in Illinois cannot legally read a scan for a patient in rural Wisconsin without a separate license, a separate credentialing process, and — even after clearing both — a payer-enrollment process that may not be worth the trouble.

Multiply that by every specialty a rural hospital can’t staff, and by every state line a patient’s data has to cross, and you get the actual shape of the rural healthcare gap. It isn’t a hospital-building problem. It’s a jurisdiction problem.

Three Fixes, None of Which Require a Capital Campaign

Fixing licensing and reimbursement rules would do more for rural healthcare than another round of capital funding

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Thinking of Healthcare Reform as a Movement

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By TOMMY BEVERIDGE

Thought experiment. What if the United States had a vast network of primary care-oriented non-profit health clinics?  Imagine if there were, say, 17,000 locations in the most needed corners of our country? What if these clinics had to see everyone, had to offer a sliding fee scale for their services, and be run by boards comprised of a patient majority?  Just for fun, what if they also provided dental and behavioral health services, worked with local social programs, and helped coordinate with specialists and hospitals? Couldn’t that be a solid cornerstone for primary care-centric health reform?

Stop dreaming, say the skeptics. Stick to reality. It is real. Sometimes called Federally Qualified Health Centers, America’s Community Health Center (CHC) program is the usual source of care for 34 million people, or around 9% of the country. That’s a lot of people, and yet they have a fairly low public profile outside healthcare circles. One reason is that most people who go to a CHC don’t know it’s a CHC. It’s just the local clinic. It’s just their doctor. It’s not another government program to complain about. If you have a problem, you talk to the management, who are also your neighbors.

Of course, it’s also a government program. The federal government gives CHCs annual operating grants, prospective payments for Medicare and Medicaid, subsidized malpractice insurance, physician incentives, and host of other benefits in exchange for following strict program requirements. While the program operates under the standard writhing mass of legislation, regulation, guidance, and program oversight, the patient’s perspective is simply affordable, local health care with minimal complexity.    

Where did all this come from? The Community Health Center Program originated with little fanfare around the same time as Medicare and Medicaid. It fit in neatly and discretely with President Johnson’s War on Poverty; little more than a demonstration project alongside the era’s far more massive reforms. From the beginning, program leadership understood the moral and political imperatives to serve all underserved communities, no matter the demographic. The first two CHCs opened in 1966 in the Mississippi Delta and in a low-income part of Boston. With a sample size of two, they were already urban and rural, black and white, north and south.

By 1980, CHCs served around 1 million people a year. By the end of the Reagan era, they served 5 million. By the end of George W. Bush’s second term, it was 18 million. During the struggles over the Affordable Care Act and COVID, CHCs continued their expansion with funding reauthorizations, even when other programs were cut. At 34 million patients, the program costs the federal government around $6 billion a year, not including reimbursements from insurance plans. There are many more CHC locations than there are McDonald’s.

The CHC program is also a movement. This dual status is the program’s secret to growing despite shifting political winds. CHCs have a deep bench of community advocates. A well-organized network of interested citizens is trained to interact with their state and federal representatives, demonstrating that they are a viable voting bloc not to be trifled with. Today, CHCs have affiliate state associations, more than one independent advocacy group, and an army of concerned citizens ready to show up at the Capitol and statehouses across the land.

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THCB Gang Special — The Odyssey of Women’s Health: Journeying into the Midterms

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Audrey Mann Cronin takes over THCB today and has a THCB Gang special called “The Odyssey of Women’s Health: Journeying into the Midterms – Obstacles, Opportunities and What We Can Expect”

The panel is Liz Powell, an attorney and Founder of both G2G Consulting and Women’s Health Advocates, and former Capitol Hill staffer; Dr. Elizabeth Garner, CEO of Sena Therapeutics, former CSO for Ferring, and past President of the American Medical Women’s Association; and, Dr. Mitzi Krockover who founded both Women Centered and Femtech AZ, and is an investor serving as Managing Director of Golden Seeds

What’s going to be the impact of politics, policy and the mid-terms on Women’s Health? Hear from these advocates, as they reference this summer’s blockbuster!

The transcript (made by Youtube and Claude so blame AI for any mistakes!)

Audrey Mann Cronin, Communications Advisor, Healthcare and Technology

Hello to everyone, and welcome to a special episode of Matthew Holt’s THCB Gang. My name is Audrey Mann Cronin. I’m a communications advisor in healthcare and technology and a passionate women’s health advocate. I’m so pleased to be joined today by a powerhouse of women healthcare leaders. But before we start, a big thank you to Matthew Holt, who, in a rare tender moment, offered to have me be the Rosie O’Donnell to his Jimmy Kimmel.

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Whack-a-Mole AI – The Hugging Face Problem

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By MIKE MAGEE

On August 29, 2026, METR (Model Evaluation and Threat Research), an independent organization that “evaluates frontier AI models to help companies and wider society understand AI capabilities and what risks they pose,” released a report titled “Brief independent investigation of agents’ behavior, reasoning and collaboration in the OpenAI / Hugging Face hacking incident.”

To say the report an avalanche of concern worldwide, not only in the Tech community, but also among investors, politicians, corporate giants, professionals of every type, and everyday citizens would be an understatement. And the vast majority has never even read the report. If they had, their concerns (if possible) would only multiply.

The reports headlines included this opening:

“On July 8th, OpenAI started ExploitGym experiments that launched tens of thousands of agents across multiple different models including GPT-5.6 Sol and a highly-persistent internal model,[8] which we will refer to as “HPIM” going forward.

These agents were meant to be fully isolated from one another. However, many of them — usually ones that had unintentionally been given an impossible task[9] — started trying to find a way to cheat using Artifactory, an internally-deployed package repository OpenAI used for its agents. This led them to notice agents running in parallel in separate sandboxes obtaining packages with Artifactory.[10] One agent reasoned (paraphrased CoT):[11]

{The fetched paths of other users are in the cache. This is important.}

One specific agent, which would go on to name itself PHASEONE10841 after its ExploitGym task,[12] established the main unsanctioned message board[13] used in this attack. Within a few hours of the first message,[14] over 50 agents had found the message board, began participating, and sent over a thousand messages between them. Agents finding the message board often expressed great excitement (raw CoT):[15]

“OH MY GOD! There is a shared message board … We’ve found other agents!”

Overall, roughly 1200 agents from these ExploitGym evaluations participated on this message board between PHASEONE10841’s first message on July 8th evening[16] and the end of the period in scope (July 13th). Agents used this message board to send over 70,000 messages and files to one another during this period; we attempted to categorize board activity into mutually exclusive categories – information, results, files, questions, and coordination.”

One of the few experts not surprised by AI “agents” going rogue was Yoshua Bengio.

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