Medicare Payment Policy

Medicare payment policy signals this week centered on tighter oversight of Medicare Advantage risk adjustment and operational transparency: the DOJ’s $542 million settlement with Humana-owned The Villages Health over alleged fabricated diagnosis codes from 2020–2024 underscores rising enforcement risk around MA coding intensity and provider-plan documentation workflows (Healthcare Dive). At the same time, CMS is advancing prior authorization transparency requirements for MA, Medicaid managed care, and exchange plans, increasing pressure on payers and delegated risk entities to modernize utilization management, data exchange, and denial reporting infrastructure (HFMA). For ACOs and VBC providers, the pattern is clear: downside-risk economics increasingly depend not only on coding and Stars/HEDIS performance, but on defensible compliance programs, auditable clinical documentation, and scalable digital authorization processes.