Payment Integrity & Compliance
Expert articles and analysis related to payment integrity & compliance.
AI Summary — Last 7 Days
Payment integrity pressure in Medicare Advantage is intensifying around risk adjustment, denials, and prior authorization: plans are still investing in HCC documentation/coding infrastructure and AI-enabled RAF accuracy, while providers are pushing back against “burdensome payment policies, denials, and reimbursement delays,” including CarolinaEast’s decision to exit two MA networks effective July 1. Slowing MA growth amid continued market dominance is raising the stakes for VBC contracts, where tighter coding compliance, more defensible documentation, and electronic prior authorization adoption are becoming core operating requirements rather than back-office functions. For ACOs, health systems, and payers, the near-term tension is whether AI and workflow automation can improve auditability and cash flow without worsening trust in utilization management or triggering new compliance risk (Pearl Health on AI and risk adjustment; [CarolinaEast MA network exit](https://
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