Payment Integrity & Compliance
Expert articles and analysis related to payment integrity & compliance.
AI Summary â Last 30 Days
Payment integrity has become a central pressure point for VBC strategy as CMS scrutinizes both CMMIâs fiscal performance and Medicare Advantage risk adjustment, with growing attention to trust fund impacts, coding intensity, star ratings litigation, and whether quality bonus and risk-score methodologies are producing defensible value-based payments rather than inflated benchmarks or arbitrary penalties. The Trump administrationâs WISeR Medicare AI prior authorization pilot is also becoming a flashpoint: Republicans blocked an effort to end the test, while Democrats are pressing CMS for more transparency, signaling that AI-enabled utilization management may expand but will face sustained oversight around access, denial rates, and model governance. For ACOs, MA plans, and risk-bearing providers, the strategic implication is clear: infrastructure for auditable documentation, real-time clinical data integration, and compliant coding is shifting from operational support to core financial defense as payment models become more tightly policed (KFF on MA coding intensity; Avalere on CMMI financial footprint).
Related Articles
Statement on House Subcommittee Approval of the Improving Seniorsâ Access to Timely Care Act
Premier applauds the House Energy and Commerce Health Subcommittee for advancing bipartisan legislation to modernize prior authorization for Medicare Advantage patients.
Democrats push for more data on Medicare AI prior authorization pilot
The letter to the CMS from Democrats is the latest salvo from lawmakers concerned that WISeR is delaying care to Medicare beneficiaries.
Medicare Advantage organizations are denying some post-acute care at high rates
Medicare Advantageâs prior authorization process is still a âWild West,â one expert says.
Prior authorization reform gets promising start from House health panel
Prior authorization reform gets promising start from House health panel  American Medical Association
Raleigh Man Pleads Guilty to Receiving More than $60 Million in Fraudulent Claims from Paying Kickbacks for Patient Referrals - Office of Inspector General (.gov)
Raleigh Man Pleads Guilty to Receiving More than $60 Million in Fraudulent Claims from Paying Kickbacks for Patient Referrals  Office of Inspector General (.gov)
DOJâs 2026 Health Care Fraud Takedown: Details Behind the Headline Number and What It Means for Health Care Providers
National Health Care Fraud Takedown Results in 455 Defendants Charged in Connection with Over $6.5 Billion in Alleged Fraud - Department of Justice (.gov)
National Health Care Fraud Takedown Results in 455 Defendants Charged in Connection with Over $6.5 Billion in Alleged Fraud  Department of Justice (.gov)
United States Reaches $1 Million Settlement over Waived Pharmacy Copays - Office of Inspector General (.gov)
United States Reaches $1 Million Settlement over Waived Pharmacy Copays  Office of Inspector General (.gov)
DOJ announces $6.5B healthcare fraud takedown with record Medicaid enforcement
DOJ announces $6.5B healthcare fraud takedown with record Medicaid enforcement  Fierce Healthcare
Massachusetts Man Charged in $5 Million Medicare Fraud Scheme as Part of National Health Care Fraud Takedown - Department of Justice (.gov)
Massachusetts Man Charged in $5 Million Medicare Fraud Scheme as Part of National Health Care Fraud Takedown  Department of Justice (.gov)