Payment Integrity & Affordability
Expert articles and analysis related to payment integrity & affordability.
AI Summary — Last 24 Hours
Payment integrity pressure is intensifying across MA, Medicaid home care, and post-acute benefits: CMS’s RADV extrapolation methodology is heightening repayment exposure for Medicare Advantage plans, while the DOJ is suing to stop alleged fraud tied to New York’s $10B Medicaid CDPAP home-care program—signals that risk-bearing entities should expect sharper scrutiny of coding, documentation, and delegated vendor oversight (Wakely RADV guide, DOJ Medicaid home-care suit.
Related Articles
CMS Could Make Drug Price Negotiations Permanent
CMS Could Make Drug Price Negotiations Permanent - What it Means for Pharma Pharmaceutical Commerce
The 340B Drug Pricing Program at a Crossroads
The 340B Drug Pricing Program at a Crossroads JAMA
Colorado wins FDA approval to import prescription drugs from Canada
Colorado wins FDA approval to import prescription drugs from Canada Becker's Hospital Review
The IRA Fixed One Medicare Part D Distortion—But Patients Now Face New Tradeoffs
By Bryce Platt, PharmD For years, Medicare Part D plans often preferred high-list/high-rebate branded multiple sclerosis (MS) drugs over lower-cost generics. That was rational behavior inside an irra...
DOJ Sues PPL, New York DOH Over Alleged CDPAP Fraud Scheme
What CMS’s hospice and home health Medicare freeze means for the industry
The Trump administration has paused new enrollment in the areas for six months.
FDA greenlights Colorado's drug import proposal
The FDA gave the go-ahead for Colorado to try importing cheaper drugs from Canada, but it remains to be seen how or when this would actually begin. In a letter Monday ...
Department of Justice Files Suit to Stop Ongoing Medicaid Fraud Related to New York’s $10 Billion Home-Care Program - Department of Justice (.gov)
Department of Justice Files Suit to Stop Ongoing Medicaid Fraud Related to New York’s $10 Billion Home-Care Program Department of Justice (.gov)
Medicare Advantage RADV Extrapolation: A Practical Guide for Plans
Learn how CMS determines Medicare Advantage RADV extrapolation, why audit outcomes can vary, and what factors drive repayment risk. Download Wakely’s practical guide for MA plans. Understand the Stati...
Express Scripts, PCMA sue to block Tennessee law breaking up PBMs and pharmacies
Express Scripts and the PBM lobby are following in CVS Caremark’s footsteps in filing complaints challenging the FAIR Rx Act, which was passed earlier this year despite vehement opposition from PBMs.