CMS & OIG Oversight

CMS and OIG oversight is tightening around Medicare payment integrity while also pushing VBC further into mandatory and technology-enabled models: CMS’s FY 2026 IPPS proposal would expand a redesigned Comprehensive Care for Joint Replacement model nationally, reinforcing a shift from voluntary participation toward mandatory episode-based accountability, while the WISeR AI prior authorization model is drawing congressional pushback over risks of delayed or denied care for Medicare beneficiaries. At the same time, CMS is moving to narrow Medicare Advantage’s perceived payment advantage and OIG enforcement is intensifying around MA risk adjustment, including scrutiny of unsupported diagnoses and a reported $36.5M settlement, signaling that plans, providers, ACOs, and enablement vendors should expect more aggressive validation of coding, medical necessity, and model governance. For VBC leaders, the strategic tension is clear: federal policy is accelerating risk-based payment and AI-enabled utilization management, but oversight bodies and lawmakers are raising the compliance bar for documentation, algorithmic accountability, and beneficiary protections (HFMA on MA payment changes; Healthcare Dive on WISeR pushback).