Compliance & Oversight
Expert articles and analysis related to compliance & oversight.
AI Summary â Last 7 Days
CMS oversight activity is intensifying across coverage, payment, and program integrity: the Trump administration finalized limits on federal Medicaid/CHIP matching funds for gender-affirming care for minors, is pursuing ACA Marketplace disenrollments tied to potentially unauthorized enrollment, and is seeking updated billing data from qualifying Advanced APM participants to release incentive payments. At the same time, prior authorization remains a central compliance flashpoint in Medicare Advantage, Medicaid managed care, and ACA plans, with 2025 data showing insurers denied at least 1 in 8 standard PA requests and wide variation by carrierâraising operational and equity risks for ACOs and VBC providers managing access, documentation, and downstream utilization (KFF prior authorization analysis). Medicaid work requirements and ACA Marketplace enrollment integrity actions are also sharpening the tension between fraud prevention and coverage stability, with potential morbidity, risk adjustment, and attribution impacts for plans and provider organizations operating in value-based arrangements (Wakely on ACA disenrollments).
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