Cost & Payment Integrity
Expert articles and analysis related to cost & payment integrity.
AI Summary — Last 7 Days
Cost and payment-integrity pressure intensified around Medicare Advantage, with OIG scrutiny of high prior-authorization denial rates for long-term acute care and inpatient rehab by the largest MA insurers reinforcing the tension between utilization management, post-acute access, and VBC total-cost accountability (OIG/MA prior authorization findings). At the same time, MA plans face growing repayment exposure from RADV extrapolation and risk-adjustment volatility, making coding governance and documentation integrity a board-level financial risk rather than a back-office compliance issue (RADV extrapolation guide). On the provider side, systems are selectively expanding downside-risk arrangements only where payer partners bring clinical collaboration and actionable data, while episode-based models such as CJR-X are pushing hospitals to pair cost control with granular performance analytics.
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