Compliance & Oversight

Compliance pressure on Medicare Advantage intensified this week as DOJ actions and settlements—including Aetna’s $117.7 million false-claims settlement and a DOJ-Elevance discovery fight—reinforced that risk adjustment, documentation, and executive accountability remain high-enforcement areas for plans and delegated VBC entities. At the same time, bipartisan House legislation targeting MA prior authorization and denial practices signals growing congressional appetite to constrain utilization management that affects post-acute, home health, and population-health workflows. CMS’s WISeR Medicare AI prior authorization model is also facing political backlash after a Washington report found approvals stretching from roughly two weeks to four-to-eight weeks, underscoring the core VBC tension: using AI and UM to manage spend while preserving timely access and avoiding compliance exposure (WISeR delays report; MA oversight bill).