Compliance & Oversight
Expert articles and analysis related to compliance & oversight.
AI Summary — Last 30 Days
Compliance pressure is intensifying around Medicare Advantage and CMS innovation models: DOJ litigation over Elevance, Aetna’s $117.7M MA false-claims settlement, and OIG risk-adjustment audit lessons point to a sustained enforcement focus on coding integrity, documentation, and plan/provider accountability in risk-based payment. At the same time, access-management tools are becoming politically exposed, with Sen. Maria Cantwell’s report finding CMS’ WISeR AI prior authorization pilot in Washington has stretched approvals from roughly two weeks to four-to-eight weeks, sharpening the tension between utilization management, beneficiary access, and VBC efficiency goals (Healthcare Dive). Bipartisan House activity targeting MA prior authorization and denial practices signals that Congress may pair fraud-and-abuse scrutiny with tighter oversight of plan operations, forcing ACOs, MA-aligned providers, and delegated-risk entities to strengthen audit readiness, appeals infrastructure, and evidence-based authorization workflows (Home Health Care News).
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