Payment Integrity & Compliance
Expert articles and analysis related to payment integrity & compliance.
AI Summary — Last 24 Hours
CMS and federal enforcement agencies are intensifying payment-integrity pressure across Medicare Advantage, Medicaid, and supplier enrollment, with immediate implications for risk adjustment, delegated networks, and VBC compliance infrastructure. The reported $541.5 million Villages Health System settlement signals expanding Medicare Advantage risk-adjustment enforcement exposure for provider-aligned models, while CMS’s move to block 11 suppliers tied to $3.4 billion in suspected fraud underscores the Trump administration’s emphasis on pre-payment controls, enrollment screening, and AI-enabled fraud detection. Medicaid risk is also rising as federal watchdog findings on California overpayments, DOJ convictions in Medicaid fraud and kickback schemes, and disputes over state-directed payment caps reinforce that ACOs, CINs, and Medicaid managed care partners need tighter documentation, referral, coding, and funds-flow oversight.
Related Articles
California Man Sentenced to 30 Years for Orchestrating $270M Medication Reimbursement Fraud Scheme Targeting Medi-Cal - Department of Justice (.gov)
California Man Sentenced to 30 Years for Orchestrating $270M Medication Reimbursement Fraud Scheme Targeting Medi-Cal  Department of Justice (.gov)
Brooklyn Adult Daycare Owner Sentenced to 76 Months in Prison for Leadership Role in $68 Million Medicaid Fraud Scheme - Department of Justice (.gov)
Brooklyn Adult Daycare Owner Sentenced to 76 Months in Prison for Leadership Role in $68 Million Medicaid Fraud Scheme  Department of Justice (.gov)
The Villages Health System $541.5 Million Settlement: A New Frontier in Medicare Advantage Risk Adjustment Enforcement - natlawreview.com
The Villages Health System $541.5 Million Settlement: A New Frontier in Medicare Advantage Risk Adjustment Enforcement  natlawreview.com
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Florida Enforcement Leaders Hold Inaugural Meeting of the Florida Anti-fraud Task Force to Enhance Federal-State Cooperation to Detect, Investigate, and Prosecute Fraud - Department of Justice (.gov)
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As Home Health Moratorium Nears Expiration, Advocates Press CMS Against Extension
Orange County Man Sentenced to 30 Years in Federal Prison for Orchestrating Massive Health Care Fraud that Submitted Nearly $270 Million in Bogus Claims - Department of Justice (.gov)
Orange County Man Sentenced to 30 Years in Federal Prison for Orchestrating Massive Health Care Fraud that Submitted Nearly $270 Million in Bogus Claims  Department of Justice (.gov)
3 convicted in $11M Medicaid fraud, kickback scheme
3 convicted in $11M Medicaid fraud, kickback scheme  Becker's ASC
CMS blocks 11 suppliers over $3.4B in suspected fraud
CMS blocks 11 suppliers over $3.4B in suspected fraud  Healthcare Finance News
U.S. Attorney Moore Capito Commends Law Enforcement Partners After 59 Arrested During “Operation Coal Country” - Department of Justice (.gov)
U.S. Attorney Moore Capito Commends Law Enforcement Partners After 59 Arrested During “Operation Coal Country”  Department of Justice (.gov)