Payment Integrity & Oversight
Expert articles and analysis related to payment integrity & oversight.
AI Summary — Last 30 Days
CMS is tightening payment integrity across both traditional Medicare and Medicare Advantage: the Trump administration’s WISeR model is moving forward as an AI-enabled prior authorization test in Medicare despite a failed Senate repeal effort, while MA plans are escalating litigation over Star Ratings methodology, Clover-related recalculations, and risk-adjustment scrutiny—signals that quality bonuses, utilization controls, and coding validation are becoming more contested revenue levers. At the same time, CMMI’s Medicare Trust Fund footprint and reporting gaps are drawing renewed attention, increasing pressure on Abe Sutton’s CMMI to prove model savings and transparency as VBC participants face more aggressive oversight of benchmark integrity, diagnosis capture, and model ROI (Avalere; Healthcare Dive on WISeR). Medicaid financing is also entering a sharper retrenchment cycle, with CMS’s provider-tax proposed rule projected to cut payments by $220 billion over 10 years—raising downstream risk for safety-net systems, Medicaid managed care plans, and ACO-like population health strategies dependent on supplemental funding stability.
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Town of Norwood Fire Department Agreed to Pay $77,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services Provided by Unlicensed Individuals - Office of Inspector General (.gov)
Town of Norwood Fire Department Agreed to Pay $77,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services Provided by Unlicensed Individuals Office of Inspector...
University Health Associates Agreed to Pay $56,925 or Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Upcoded Evaluation and Management Services - Office of Inspector General (.gov)
University Health Associates Agreed to Pay $56,925 or Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Upcoded Evaluation and Management Services Office of Inspector Gene...
City of Tempe Agreed to Pay $1 Million for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services Provided by Unlicensed Individuals and Services Containing Invalid Signatures - Office of Inspector General (.gov)
City of Tempe Agreed to Pay $1 Million for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services Provided by Unlicensed Individuals and Services Containing Invalid Sig...
Aspirus St. Luke’s Hospital Agreed to Pay $276,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services for Services that Were Not Medically Necessary or Failed to Meet Coverage Criteria - Office of Inspector General (.gov)
Aspirus St. Luke’s Hospital Agreed to Pay $276,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services for Services that Were Not Medically Necessary or Failed t...
Cookeville Regional Medical Center Agreed to Pay $20,000 for Allegedly Violating the Civil Monetary Penalties Law by Employing an Excluded Individual - Office of Inspector General (.gov)
Cookeville Regional Medical Center Agreed to Pay $20,000 for Allegedly Violating the Civil Monetary Penalties Law by Employing an Excluded Individual Office of Inspector General (.gov)
Residential Home Health Agreed to Pay $379,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services Provided by an Unlicensed Individual - Office of Inspector General (.gov)
Residential Home Health Agreed to Pay $379,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services Provided by an Unlicensed Individual Office of Inspector Gene...
Loudoun County Department of Fire Rescue and Emergency Management Agreed to Pay $29,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services Provided by an Unlicensed Individual - Office of Inspector General (.gov)
Loudoun County Department of Fire Rescue and Emergency Management Agreed to Pay $29,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims for Services Provided by an Unlice...
Security Health Plan of Wisconsin Agreed to Pay $1.3 Million for Allegedly Violating the Civil Monetary Penalties Law by Paying Improper Remuneration in the Form of Excess Compensation - Office of Inspector General (.gov)
Security Health Plan of Wisconsin Agreed to Pay $1.3 Million for Allegedly Violating the Civil Monetary Penalties Law by Paying Improper Remuneration in the Form of Excess Compensation Office of Insp...