Compliance & Payment Integrity
Expert articles and analysis related to compliance & payment integrity.
AI Summary — Last 30 Days
Payment integrity pressure in Medicare Advantage is intensifying as HHS OIG audits and DOJ False Claims Act settlements target risk-adjustment diagnosis coding, including new OIG findings against HumanaChoice and UnitedHealthcare contracts and a $22.5M DOJ settlement with Independence Blue Cross over alleged inflated MA diagnoses. For VBC stakeholders, the strategic implication is that coding-driven revenue models, delegated risk arrangements, and provider-sponsored MA partnerships face higher audit exposure and repayment risk, shifting emphasis toward documentation governance, encounter-level clinical validation, and defensible population-risk capture rather than retrospective chart optimization. In parallel, CMMI under Abe Sutton is positioning the WISeR prior authorization/payment-integrity pilot as a broader model for reducing wasteful services, even as providers cite technology failures and administrative burden—signaling a Trump CMS posture that pairs innovation models with tighter utilization control and fraud-risk scrutiny across federal programs (OIG MA audit coverage; DOJ Independence Blue Cross settlement).
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