Cost of Care
Expert articles and analysis related to cost of care.
AI Summary — Last 7 Days
Medicare Advantage cost-of-care scrutiny intensified as Humana-owned The Villages Health agreed to a $541.5M–$542M settlement over alleged manufactured diagnosis codes from 2020–2024, reinforcing DOJ/CMS pressure on risk-adjustment integrity and raising compliance risk for MA-aligned provider groups pursuing capitated or delegated-risk economics (Healthcare Dive). At the same time, CMS is tightening prior authorization transparency requirements across MA, Medicaid managed care, and ACA marketplace plans, signaling that the Trump administration’s cost-control agenda is pairing fraud enforcement with operational oversight of utilization management (HFMA). For VBC stakeholders, the week’s pattern is clear: payment innovation and delegated risk remain active, but coding practices, specialty-model accountability, and plan-provider administrative friction are becoming central battlegrounds for total cost-of-care performance.
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