Oversight, Fraud & Compliance
Expert articles and analysis related to oversight, fraud & compliance.
AI Summary — Last 7 Days
Synthesis:
In the past week, federal enforcement activity has intensified around fraud, risk adjustment, and Medicaid oversight, signaling a sharpened regulatory posture under the Trump administration. CMS has suspended hundreds of home health and hospice organizations for alleged Medicare fraud totaling over $600 million, while new guidance on Medicaid State Directed Payments (SDPs) suggests temporary payment surges for hospitals could precede stricter federal scrutiny (“the Medicaid SDP false plateau”)—posing planning challenges for ACOs and risk-bearing providers. Additionally, the Office of Inspector General’s recent risk adjustment audit exposes ongoing vulnerabilities in Medicare Advantage coding and reimbursement, increasing pressure on value-based organizations to ensure documentation integrity and proactive compliance.
Relevant sources: Feds Suspend 23 Home Health Orgs, 447 Hospices Over $600M Medicare Fraud, The Medicaid SDP “False Plateau:” Why Hospitals May See a Surge Before the Cliff, Pulling Back the Curtain: Lessons from a OIG Risk Adjustment Audit
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