Payment Integrity Oversight
Expert articles and analysis related to payment integrity oversight.
AI Summary — Last 30 Days
CMS and HHS are tightening payment-integrity scrutiny around Medicare Advantage and utilization management, with recent OIG findings that major MA plans denied post-acute prior authorization requests at unusually high rates—often later overturned—intensifying the policy argument that MA risk-bearing incentives may be producing underuse rather than value (OIG/MA prior authorization findings). At the same time, the Trump administration’s WISeR Medicare AI prior authorization model is becoming a flashpoint: congressional Democrats and the House Appropriations Committee are moving to block or roll back the pilot amid concerns that algorithmic review could institutionalize care delays in traditional Medicare (House action on WISeR). For ACOs, health systems, and payer strategists, the structural signal is clear: “payment integrity” is shifting from retrospective coding and claims audits toward front-end authorization, AI governance, and post-acute network control—raising both compliance risk and competitive opportunity for organizations that can prove appropriate utilization without appearing to restrict necessary care.
Related Articles
3 men sentenced for $6.9M orthotic DME fraud scheme
Three Florida men have been sentenced to prison for their roles in a scheme to submit nearly $7 million in fraudulent Medicare claims for medically unnecessary orthotic braces and launder more than $2...
HHS launches AI-backed health fraud crackdown
The department will use AI to examine audits from states and other federal grant recipients, and potentially withhold funds if they aren’t able to fix errors.
HHS launches AI-powered audit crackdown on states, grantees
Minnesota Health Care Fraud Takedown Results in Charges Against 15 Defendants for Over $90M in Fraud - Department of Justice (.gov)
Minnesota Health Care Fraud Takedown Results in Charges Against 15 Defendants for Over $90M in Fraud Department of Justice (.gov)
HLB’s Fraud & Abuse Blog | Hooper Lundy & Bookman
OIG Rejects Physician Royalty Structure in Orthopedic Device Consulting Arrangement
New Bill Targets Scams Within Home Health, Hospice Services
CMS Imposes Nationwide Enrollment Moratoria for Home Health Agencies and Hospices
Healthcare compliance risks rise as CMS expands fraud enforcement
With recent developments highlighting the Trump administration’s emphasis on healthcare fraud prevention, providers should ensure their compliance processes are working optimally. The administration h...
Under Pressure: Why Pre-Bill Prevention is Now Non-Negotiable in Coding and Denial Management
The following is a guest article by Ritesh Ramesh, CEO at MDaudit Healthcare organizations are operating in an environment defined by financial pressure, regulatory scrutiny, and rapid shifts in payer...