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...