Compliance & Oversight
Expert articles and analysis related to compliance & oversight.
AI Summary â Last 24 Hours
Prior authorization oversight is tightening across Medicare Advantage, Medicaid managed care, and ACA Marketplace plans: KFFâs review of 2025 data finds insurers denied at least 1 in 8 standard PA requests, with wide variation by payer, reinforcing compliance risk around access, transparency, and appealability for risk-bearing providers and ACO-aligned networks (KFF analysis). In parallel, HHS OIG found Kansas failed to ensure Medicaid MCO compliance with mental health and substance use disorder parity requirements tied to prior authorization, signaling continued federal scrutiny of delegated plan oversight, behavioral health access, and state Medicaid accountability (HHS OIG report)
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Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain
This analysis of available 2025 prior authorization data finds insurers denied at least 1 in 8 standard requests for prior authorization across three insurance markets: Medicare Advantage, Medicaid ma...
What CMSâ 2027 AI rule means for prior authorization (and maybe for fax machines)
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HHS report raises scrutiny of gender-affirming care billing and coding
HHS followed up its final rule blocking Medicaid funding for gender-affirming care in minors by publishing a commissioned report alleging âpotentially fraudulentâ billing and coding among providers of...
Where prior authorization stands â and where data still falls short
Where prior authorization stands â and where data still falls short  Becker's Payer Issues
Assistant Attorney General Colin M. McDonald Issues Memorandum on the National Fraud Enforcement Divisionâs Enforcement Priorities - Department of Justice (.gov)
Assistant Attorney General Colin M. McDonald Issues Memorandum on the National Fraud Enforcement Divisionâs Enforcement Priorities  Department of Justice (.gov)
Kansas Did Not Ensure That Its Medicaid Managed Care Organizations Complied With Mental Health and Substance Use Disorder Parity Requirements Related to Prior Authorization - Office of Inspector General (.gov)
Kansas Did Not Ensure That Its Medicaid Managed Care Organizations Complied With Mental Health and Substance Use Disorder Parity Requirements Related to Prior Authorization  Office of Inspector Genera...
Closing the Prior Authorization Information Gap: What Independent Pharmacies Can Do Right Now
Appeals Court Sides with Providers in No Surprises Act Pay Dispute
Appeals Court Sides with Providers in No Surprises Act Pay Dispute  MedCity News
Cotiviti Launches AI Solution to Address Coordination of Benefits Issues
Cotiviti Launches AI Solution to Address Coordination of Benefits Issues  MedCity News