Payer Operations
Expert articles and analysis related to payer operations.
AI Summary — Last 24 Hours
Medicare Advantage operational risk intensified as judges pressed HHS on its MA audit methodology, while provider groups escalated objections to payer downcoding and prior authorization practices that directly affect risk adjustment, revenue integrity, and care-management workflows. At the market level, MA remains attractive for aligned payer-provider growth—Sutter Health and SCAN are expanding co-branded MA offerings—yet member-facing price and benefit changes at HMSA underscore rising plan design volatility for seniors and downstream network partners. Medicaid managed care is also shifting at scale, with Molina assuming a $6B Florida Medicaid/CHIP contract, reinforcing the need for VBC organizations to reassess payer concentration, attribution flows, and state-level compliance exposure across MA and Medicaid populations. [STAT on MA audits](https://news.google.com/rss/articles/CBMilAFBVV95cUxQMHhUdmt3SGJlVEFvOUhIT21KbFowS3lYYjM4ei1oaDZfcnk3ZEMwbmEzaE50WmhZbGl2ZGd2Tzk3OXJvSmZwa3p3U09QT082YkFzdG0xcWZvRlFDYzVvcEEwSGp0cW5Obmpzb3hBOWVhQ0o2dWU4VEMxMmR5cTJMVnZuWkhodFBqeG9IdGIwSGlHLWh
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