Gawenda Seminars & Consulting, Inc.

04/02/2026

So if hospital systems go out-of-network with Medicare Advantage plans from Aetna, Anthem, BCBS, Humana, and UnitedHealthcare, why do therapy private practices struggle so much with this decision?

04/02/2026

If you’re in outpatient therapy, you already know this..

Reimbursement is getting tighter, documentation expectations are getting higher and the rules are constantly changing.

This episode The Will Power Podcast by Will Humphreys dives into the reality of running a therapy practice in today’s landscape from CPT coding and audits to reimbursement strategy and what’s coming next in 2027.

The clinics that understand the system and know how to work within it are the ones that stay open, grow and continue serving patients long-term.

If you want to sharpen how you think about documentation, billing, and the business side of therapy.. this is worth a listen.

https://www.buzzsprout.com/2291391/episodes/18928235

04/01/2026

Maintenance therapy is covered more often than people think.. just not by everyone.

Knowing who pays (and who doesn’t) matters.

Members can access the full FAQ page on maintenance therapy here ⬇️
https://gawendaseminars.com/faq/maintenance-therapy/

03/31/2026

NCCI Edits Version 32.1 go into effect April 1, and they directly impact how your claims are processed and paid.

I still see too many providers finding out about these edits after a denial shows up. At that point, you’re already behind.

Knowing which code combinations are allowed, and when a modifier like 59 is required, can make the difference between getting paid and not.

We’ve put together updated Medicare and Medicaid reference sheets to help you quickly identify what’s billable and what’s not.

Take a few minutes to review the latest updates before April 1. It’s a small step that can save you a lot of time and frustration later.

Click the link below 🔗
https://gawendaseminars.com/ncci-edits-version-32-1-in-effect-april-1-2026/

03/30/2026

Do you know the difference between maintenance therapy and rehabilitative therapy?

Watch this video.

I've got a full FAQ section that dives deeper on this topic here:
https://gawendaseminars.com/faq/maintenance-therapy/

03/26/2026

Team Rehab Physical Therapy agrees to pay nearly $5 Million to resolve False Claims Act allegations related to fraudulent billing scheme

The settlement resolves allegations that, from January 1, 2018, through December 31, 2024, Team Rehab knowingly and improperly submitted false claims to Medicare, Medicaid, TRICARE, the Federal Employees Health Benefits Program (FEHBP), and the United States Department of Veterans Affairs for time-based CPT codes for one-to-one physical therapy services even though those services occurred in a group setting where the provider did not maintain sufficient direct patient contact throughout the service to appropriately bill for those time-based CPT codes.

BTW, this was a whistleblower case and that individual will receive over $900,000.00.

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03/26/2026

Most providers know that Medicare uses NCCI edits. Many assume Medicaid does too. But what about every other insurance company?

That’s where things get tricky because the real answer is.. you have to check.

And often, you don’t find out until after the claim is submitted.

Your EOB or ERA will tell you. If a service wasn’t paid, don’t just move on. Look at the denial reason. If it says a code is “included” in another service, that’s your clue that NCCI edits were applied.

From there, it may be appropriate to append modifier 59 and resubmit.

Small details like this can be the difference between getting paid or leaving money on the table.

Take the extra minute to review your remittances. It matters more than you think.

03/25/2026

Good care isn’t enough if it’s not documented well.

If you’re seeing denials tied to medical necessity, there’s a good chance the issue isn’t what’s being done.. it’s how it’s being documented.

This upcoming webinar, 2026 Documentation for Everything after the Initial Evaluation for PT, OT, & SLP, breaks down what needs to be included after the initial evaluation—from daily notes to progress reports to Medicare requirements—so your documentation clearly supports your clinical decision-making.

📅 April 9th

🔗 Get more information here
https://gawendaseminars.com/events/2026-documentation-for-everything-after-the-initial-evaluation-for-pt-ot-slp/

03/24/2026

Getting a request for medical records from an insurance carrier can feel straightforward.. until your claim gets denied anyway.

We’re seeing more frequent requests from Medicare and commercial payers asking for documentation tied to specific dates of service. And in many cases, providers are documenting the visit well—but still missing key pieces when it comes time to submit records.

That’s where things fall apart.

It’s not just about what happened during that visit.. it’s about submitting the right combination of documentation based on where that visit falls within the plan of care.

In this week’s article, we’ll break down exactly what you need to submit when:
▪️ The visit falls within the first 9 visits
▪️ Visits 10–19
▪️ Visits 20–29
▪️ And how this differs for commercial insurance carriers

If you’ve ever been confused about what to send (or frustrated by denials that don’t seem to make sense), this is one you’ll want to read.

Members can access it here 🔗
https://gawendaseminars.com/documentation-to-submit-when-an-insurance-carrier-requests-a-date-of-service/

03/23/2026

I will be doing an onsite seminar on May 15, 2026 in the Denver/Boulder, CO area. The seminar will discuss Documentation, CPT Coding, and Billing for PT, OT, and SLP and will cover pediatrics to geriatrics.

The seminar is approved for 7.0 CEUs for all 3 disciplines. There will be a Networking Social immediately following the seminar.

For additional information and to register, click below.

This seminar will teach participants what they need to know about documentation, CPT Coding, NCCI Edits, and Billing

03/23/2026

You’ve probably heard of NCCI edits… but do you actually know what they are and how they impact your payments?

The National Correct Coding Initiative (NCCI) was created by Medicare to promote accurate coding and reduce improper payments.

NCCI edits apply across all outpatient therapy settings—from private practices to hospital outpatient departments, skilled nursing facilities, home health (Part B), and more.

Which means if you’re providing outpatient therapy services, they apply to you.

And if you’re not fully understanding or using them correctly, it could be one of the reasons your claims are being denied or underpaid.

If you’re running into challenges with NCCI edits or not getting paid what you should be, don’t try to figure it out alone.

Reach out directly. I can help you navigate the complexities and make sure you’re getting paid correctly for the services you provide. Or keep following along for more information on this topic!

03/20/2026

NCCI edits aren’t something you check once and move on from. They’re updated every quarter—January, April, July, and October.

And those updates matter.

If you’re billing outpatient therapy services using outdated edits, it can lead to denials, delays, or even compliance issues.. all from something that’s completely avoidable.

Yes, the biggest changes usually happen at the start of the year. But that doesn’t mean the rest of the year is quiet.

Things still change. And if you’re not keeping up, it can quietly impact your revenue.