Payment Integrity & Affordability
Expert articles and analysis related to payment integrity & affordability.
AI Summary — Last 7 Days
Payment integrity pressure intensified across Medicare Advantage and post-acute care: HHS OIG findings that major MA insurers denied prior authorization for LTACH, inpatient rehab, and SNF care at unusually high rates—while nearly all appealed SNF denials were overturned—are sharpening scrutiny of whether utilization management is reducing inappropriate spend or blocking medically necessary care in ways that undermine VBC care transitions and total-cost accountability (OIG/MA prior auth findings). At the same time, Congress moved to constrain CMS’s AI-enabled prior authorization ambitions, with the House Appropriations Committee taking a step toward blocking the WISeR Medicare pilot, signaling bipartisan discomfort with automating payment-integrity tools before access, transparency, and appeals safeguards are trusted (WISeR pilot pushback). For MA plans, ACOs, and providers, the week’s pattern is clear: the Trump administration’s affordability and anti-waste agenda is colliding with provider and lawmaker concerns that aggressive PA, RADV extrapolation, and enrollment freezes in home health/hospice could create financial uncertainty and disrupt care pathways central to value-based performance.
Related Articles
CMS proposes permanent framework for Medicare drug price negotiations
CMS proposes permanent framework for Medicare drug price negotiations  Fierce Healthcare
STAT+: Trump administration revisits policy to close Medicare drug price negotiation loophole
Trump administration revisits policy to plug Medicare drug price negotiation loophole.
UnitedHealth, FTC reach proposed settlement in insulin case
The tentative deal comes months after CVS Health reached a proposed settlement in the lawsuit alleging major pharmacy benefit managers are inflating insulin costs.
Click here to see the original post from April 2026.
Stretching Scarce Authorizing Legislation as Far as Possible: A Legislative History of the 340B Drug Pricing Program
From newsletter: Public Policy Cornerstones of America’s Financialized Health Care System Which public policies corporatized the US health care system? ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ‌ ...
Shifting Upstream in Payment Integrity: Why Prepay Prevention is Becoming the New Standard
The following is a guest article by Steve Sutherland, SVP Information Systems at CERIS Payment integrity often lives at the end of the claims line, with teams measuring success by how much they can wi...
From Detection to Defense: Building Fraud-Resilient Healthcare Payment Systems
Prevention requires more than faster detection. Organizations need payment programs with end-to-end visibility and controls that intervene before losses occur. The post From Detection to Defense: Bui...
STAT+: As the U.S. looks on, European countries feel growing pressure on drug prices
In Europe, two divergent paths are emerging as countries grapple with what to do about drug prices, affecting both pharma and patients — and testing the influence of the U.S.
Ohio’s Medicaid Enforcement Surge Raises Stakes For At-Home Care Providers Nationwide
Optum Rx, FTC posed for settlement in insulin pricing case
Optum Rx, FTC posed for settlement in insulin pricing case  Fierce Healthcare