Cost & Payment Integrity
Expert articles and analysis related to cost & payment integrity.
AI Summary — Last 30 Days
CMS is tightening payment integrity across Medicare Advantage and Medicare FFS: the 2027 MA rate announcement signals a push to narrow MA’s perceived payment advantage over providers, while RADV extrapolation is becoming a material balance-sheet risk for plans as audit repayments become more enforceable and statistically consequential. At the same time, congressional scrutiny of CMS’s Medicare AI prior authorization pilot reflects a broader tension between using automation to curb unnecessary spending and protecting beneficiary access—an issue that will shape payer-provider trust in VBC arrangements. On the care-model side, specialty VBC continues to mature, with Blue Cross NC’s Advanced Kidney Care program showing how risk-aligned nephrology partnerships can connect affordability goals with outcomes management for CKD and ESRD populations (HFMA on MA payment policy; HCTTF on Advanced Kidney Care).
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