Payment Integrity & Compliance
Expert articles and analysis related to payment integrity & compliance.
AI Summary — Last 30 Days
DOJ/CMS payment integrity enforcement is moving deeper into Medicare Advantage risk adjustment, with the $541.5M Villages Health settlement alleging unsupported diagnosis codes from 2020–2024 and signaling that provider groups, not just MA plans, face major False Claims Act exposure when VBC economics depend on unsupported coding intensity (Healthcare Dive). For ACOs, MA risk-bearing providers, and payer partners, the strategic posture is shifting from retrospective chart defense to enterprise coding governance, encounter-data controls, and AI-enabled compliance workflows, reinforced by renewed scrutiny of plan-level MA risk-adjustment accuracy from MedPAC (MedPAC). At the same time, CMS prior authorization transparency requirements for MA, Medicaid managed care, and ACA marketplace plans are increasing operational accountability around utilization management—tightening the compliance perimeter around both revenue capture and medical-cost control in value-based contracts.
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