Fraud, Compliance & Oversight

CMS, under the Trump administration, has intensified its enforcement and oversight posture in value-based care, as evidenced by large settlements with major payers like Kaiser and Aetna for Medicare-related fraud and inaccurate risk adjustment submissions. Alongside these actions, CMS has finalized a mandatory Ambulatory Specialty Payment Model in the 2026 Physician Fee Schedule, set to launch January 2027, that will hold outpatient specialists financially accountable for managing chronic conditions, further shifting Medicare reimbursement toward quality and cost performance. These measures signal a structural move toward stricter compliance and financial accountability across Medicare Advantage, ACOs, and specialty care providers, raising the stakes for risk-adjusted coding accuracy and integrated care delivery. See further details in CMS’ ambulatory specialty payment model: 10 things to know and Kaiser affiliates will pay $556 million to settle a lawsuit alleging Medicare fraud.