Payment Integrity & Oversight
Expert articles and analysis related to payment integrity & oversight.
AI Summary — Last 30 Days
Payment integrity enforcement is tightening around Medicare Advantage risk adjustment, with HHS OIG audits of UnitedHealthcare and Humana contracts alleging unsupported diagnosis codes and sizable overpayments, while DOJ settlements such as Independence Blue Cross’ $22.5M FCA resolution reinforce that coding programs are now a sustained fraud-and-abuse priority rather than episodic scrutiny. At the same time, CMS under the Trump administration is testing more prospective utilization controls through CMMI’s WISeR model, which CMS has positioned as a potential template despite provider concerns over prior authorization burden, AI-enabled review reliability, and operational readiness. For ACOs, MA plans, and risk-bearing providers, the strategic signal is clear: documentation, coding governance, model compliance, and utilization-management infrastructure are becoming core VBC capabilities as payment models face more aggressive oversight on both risk adjustment and service appropriateness.
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Khadeer Khan Mohammed - Office of Inspector General (.gov)
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Brandon Pulmonary Practice Agrees to Pay Over $400,000 to Resolve False Claims Act Violations - Office of Inspector General (.gov)
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