Payment Integrity & Compliance
Expert articles and analysis related to payment integrity & compliance.
AI Summary — Last 30 Days
Payment integrity pressure in Medicare Advantage is intensifying as DOJ/OIG enforcement and CMS risk-adjustment scrutiny converge with payer litigation over Star Ratings: Independence Blue Cross agreed to pay $22.5M to resolve allegations it inflated MA diagnosis codes, while OIG’s audit of UnitedHealthcare Benefits of Texas reinforces continued federal focus on unsupported risk-adjustment submissions and RADV exposure (DOJ settlement). At the same time, CVS Health and Centene are pursuing high-stakes challenges tied to Star Ratings and quality-bonus methodology, signaling that MA revenue, compliance, and quality infrastructure are becoming more legally contested as plans defend billions in margin-sensitive payments (Centene Star Ratings suit). For VBC stakeholders, the strategic takeaway is clear: risk-bearing providers, ACO-aligned groups, and payer partners need tighter documentation, coding governance, encounter-data validation, and quality-measure controls as payment integrity increasingly determines both downside audit liability and upside performance revenue.
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