Oversight & Compliance
Expert articles and analysis related to oversight & compliance.
AI Summary — Last 24 Hours
Oversight pressure is intensifying around Medicare Advantage and prior authorization, with AMA pushing for payer PA data that is easier to access and compare while major technology vendors back PA reform infrastructure—raising expectations that MA plans will face more transparency, interoperability, and administrative-performance scrutiny in VBC contracts. At the same time, HHS OIG enforcement remains active, including sentencing in a $46M telemedicine Medicare fraud scheme and a separate multimillion-dollar Medicare fraud case, reinforcing the need for ACOs, MA risk-bearing providers, and delegated entities to tighten documentation, vendor oversight, utilization controls, and claims-monitoring compliance.
Related Articles
Harlingen couple sentenced in multimillion-dollar Medicare fraud scheme - Office of Inspector General (.gov)
Harlingen couple sentenced in multimillion-dollar Medicare fraud scheme Office of Inspector General (.gov)
Harlingen couple sentenced in multimillion-dollar Medicare fraud scheme - Office of Inspector General (.gov)
Harlingen couple sentenced in multimillion-dollar Medicare fraud scheme Office of Inspector General (.gov)
Telemedicine Company Owner Sentenced to 20 Years in Prison for $46M Medicare Fraud Scheme - Office of Inspector General (.gov)
Telemedicine Company Owner Sentenced to 20 Years in Prison for $46M Medicare Fraud Scheme Office of Inspector General (.gov)
Telemedicine Company Owner Sentenced to 20 Years in Prison for $46M Medicare Fraud Scheme - Office of Inspector General (.gov)
Telemedicine Company Owner Sentenced to 20 Years in Prison for $46M Medicare Fraud Scheme Office of Inspector General (.gov)
Employers accuse UnitedHealth of overpaying medical claims
Six large US companies sued UnitedHealth Group, accusing the health insurance giant of overpaying for workers’ medical claims and driving up their costs. Aramark, Whirlpool, Grainger, Kraft Heinz Fo...
Inside Intermountain’s RCM denials strategy
Intermountain Health executives have ramped up the health system’s revenue cycle management (RCM) AI and machine learning to prevent what they believe are excessive billing denials from insurers. It’s...
Office of Public Affairs | New York Woman Charged With $1.1M Check Cashing Scheme - Department of Justice (.gov)
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STAT+: House lawmaker probes PBMs for ‘punitive’ audits of independent pharmacies
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CMS proposes heightened standards for ACA financial assistance
Enrollees must jump through more hoops to verify their income and residency status before receiving subsidies for Affordable Care Act plans. Over 300,000 enrollees are expected to leave each year as a...
Kraft Heinz, Ralph Lauren among large employers suing UnitedHealth over alleged improper claim approvals
Kraft Heinz, Ralph Lauren among large employers suing UnitedHealth over alleged improper claim approvals Becker's Payer Issues