Compliance & Oversight
Expert articles and analysis related to compliance & oversight.
AI Summary — Last 30 Days
Compliance risk in VBC is tightening around both sides of the MA/value-based care playbook: DOJ/OIG enforcement on risk adjustment and CMS oversight of utilization management. The $14.1M False Claims Act settlement with Complete Health over allegedly unsupported MA diagnosis coding underscores that value-based primary care groups, MSOs, and MA-aligned providers face growing exposure when population-health documentation infrastructure becomes tied to revenue maximization rather than clinical evidence (DOJ/OIG settlement coverage). At the same time, the Trump administration’s WISeR AI prior-authorization test is moving forward after Senate Republicans blocked repeal efforts, signaling that CMS is willing to test algorithmic utilization controls in Medicare even as KFF data show persistent denial-rate variation and transparency gaps across MA, Medicaid managed care, and ACA markets (WISeR Senate vote).
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STAT+: GOP blocks effort to end Medicare test of AI prior authorization
The Trump administration is testing the use of AI in Medicare to approve some medical services.
Novitas Solutions, Inc., Improperly Paid Approximately $19.5 Million for Selected Medicare Part B Services Provided to Patients Residing in Nursing Homes - Office of Inspector General (.gov)
Novitas Solutions, Inc., Improperly Paid Approximately $19.5 Million for Selected Medicare Part B Services Provided to Patients Residing in Nursing Homes Office of Inspector General (.gov)
Health Plans Are on Track to Streamline Prior Authorization
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Novitas Solutions, Inc., Improperly Paid Approximately $19.5 Million for Selected Medicare Part B Services Provided to Patients Residing in Nursing Homes - Office of Inspector General (.gov)
Novitas Solutions, Inc., Improperly Paid Approximately $19.5 Million for Selected Medicare Part B Services Provided to Patients Residing in Nursing Homes Office of Inspector General (.gov)
Senate rejects effort to halt Medicare AI prior authorization pilot
Senate rejects effort to halt Medicare AI prior authorization pilot Healthcare Finance News
Doctors cheer payment bill as Senate keeps AI prior auths in Medicare
One year later, insurers hedge on prior authorization pledge
One year later, insurers hedge on prior authorization pledge Modern Healthcare
Insurers Hedge on Trump-Backed Pledge To Improve Denials Process
Last year, the Trump administration announced a voluntary commitment by dozens of insurers to improve a process called prior authorization, which often requires patients or their doctors to seek appro...