Payment Integrity Oversight

Payment integrity oversight sharpened this week around Medicare Advantage prior authorization and CMS’ WISeR pilot, with the House Appropriations Committee voting unanimously to block funding for the AI-enabled prior authorization demonstration amid concerns it could delay access for seniors (Healthcare Dive). At the same time, HHS OIG findings that the largest MA insurers denied post-acute prior authorization requests at unusually high rates—while MA plans overturned nearly all appealed SNF admission denials—intensify scrutiny of whether utilization management is functioning as legitimate payment integrity or as inappropriate care restriction in value-based models (MedCity News). For ACOs, MA plans, and provider groups, the signal is clear: federal oversight is moving toward tighter validation of AI, prior authorization, and risk-adjustment controls, especially where “cost management” may conflict with timely post-acute care and population health outcomes.