Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary — Last 30 Days
Payment integrity is moving from retrospective audit to active payment-model design: HHS OIG audits of HumanaChoice and UnitedHealthcare of Wisconsin found Medicare Advantage risk-adjustment overpayments tied to unsupported diagnosis codes, reinforcing DOJ/OIG scrutiny of MA coding programs and raising compliance risk for plans, delegated groups, and VBC providers that rely on documentation-driven revenue capture (HHS OIG audit coverage). At the same time, under the Trump administration, CMMI Director Abe Sutton is positioning the WISeR prior authorization model as a broader template for reducing “wasteful and inappropriate” services in Medicare, even as provider pushback and reports of AI/technology failures create operational and access-risk tensions for hospitals and ACO participants (WISeR model positioning). The strategic signal for VBC stakeholders is clear: risk adjustment, utilization management, and AI-enabled payment controls are converging, making defensible coding, evidence-based care pathways, and audit-ready data infrastructure central to both revenue protection and model participation.
Related Articles
The Next Era of Payment Integrity is Prevention, Not Recovery
The following is a guest article by Anne Neal, Vice President of Product Management for Payment Accuracy at Availity As Payment Integrity Programs Face Rising Administrative and Provider Friction, the...
Trump admin blocks over $1.6B in potentially fraudulent Medicare lab payments: CMS
Trump admin blocks over $1.6B in potentially fraudulent Medicare lab payments: CMS Fierce Healthcare
Trump admin blocks over $1.6B in potentially fraudulent Medicare lab payments: CMS
Trump admin blocks over $1.6B in potentially fraudulent Medicare lab payments: CMS Fierce Healthcare
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only - Office of Inspector General (.gov)
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only Office of ...
OIG: Medicare Part D plans spent millions on ineligible drugs
OIG: Medicare Part D plans spent millions on ineligible drugs Fierce Healthcare
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. - 24/7 Wall St.
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. 24/7 Wall St.
Conflicting CMS Guidance and Federal Statutory Requirements Cost Medicare $380 Million Over a 6-Year Period for Organs Not Transplanted Into Medicare Enrollees - oig.hhs.gov
Conflicting CMS Guidance and Federal Statutory Requirements Cost Medicare $380 Million Over a 6-Year Period for Organs Not Transplanted Into Medicare Enrollees oig.hhs.gov
Catching Errors Before Claims Go Out: How Mature Home Health Agencies Prevent Billing Mistakes
Medicare spent hundreds of millions of dollars on ineligible drugs, audit finds
Shoddy CMS oversight is to blame, and the agency needs to do better, the HHS Office of the Inspector General said. The CMS concurred.
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only - Office of Inspector General (.gov)
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only Office of ...