Payment Integrity & Affordability
Expert articles and analysis related to payment integrity & affordability.
AI Summary — Last 30 Days
CMS is pairing affordability pressure with stronger payment-integrity scrutiny: DOJ’s $14M settlement with Complete Health over alleged Medicare Advantage upcoding underscores heightened risk-adjustment enforcement, while new CMS-required prior authorization data showing insurer denial rates ranging from 2% to 25% increases transparency pressure on MA and managed care plans. At the same time, CMS finalized a 2.3% inpatient hospital payment update for 2027 and the first nationwide mandatory joint replacement bundle beginning in 2028, signaling that the Trump administration is willing to use mandatory models—not just voluntary VBC—to constrain episode costs despite hospital pushback (hospital rule and TJR model). Medicaid financing is also tightening, with KFF estimating that $60B in federal Medicaid hospital-directed payments across 37 states could exceed new reconciliation-law limits, creating a material revenue and network-stability risk for hospitals, ACO partners, and safety-net VBC strategies (KFF analysis).
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