Payment Integrity & Affordability
Expert articles and analysis related to payment integrity & affordability.
AI Summary — Last 30 Days
CMS’s payment-integrity posture is hardening around Medicare Advantage and utilization management: the 2027 MA rate announcement is being read as an effort to narrow MA plans’ “unfair payment advantage,” while RADV extrapolation and OIG scrutiny of high denial rates in LTACH and inpatient rehab prior authorization increase downside risk for MA plans and delegated risk entities. At the same time, the Trump administration’s WISeR AI prior authorization model is becoming a political flashpoint, with House and Senate Democrats moving to block it amid concerns that AI-enabled payment controls could delay or deny care for seniors—creating a strategic tension for VBC organizations between affordability tools and patient-access accountability. For ACOs, health systems, and MA-aligned providers, the implication is clear: success in VBC will depend less on coding and utilization arbitrage and more on defensible risk adjustment, evidence-based authorization processes, and measurable care-management outcomes that can withstand CMS, OIG, and congressional scrutiny (HFMA on MA payment advantage; Healthcare Dive on WISeR pushback).
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Virginia governor vetoes prescription drug pricing bills
Where PBM reform stands across the US
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Nine states have been pursuing the idea of prescription drug affordability boards. Maryland's board just set limits on the price of Ozempic.
Supreme Court declines to hear drugmakers' challenge to price negotiations
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STAT+: Supreme Court rejects challenge to Medicare drug price negotiation
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