Payment Integrity & Oversight
Expert articles and analysis related to payment integrity & oversight.
AI Summary — Last 7 Days
Payment integrity pressure is intensifying across Medicare Advantage, Medicaid, and hospital payment: Health Affairs’ risk-adjustment pieces point to growing scrutiny of MA coding algorithms and the need for technology-enabled risk-adjustment reform, while AHIP is pushing back on MedPAC assumptions—signaling continued payer-provider tension over whether MA “value” reflects true care management or diagnosis-driven revenue capture. Medicaid oversight is also tightening as courts allow work requirements to proceed and hospitals challenge CMS’ proposed implementation of state-directed payment limits under OBBBA, raising operational and coverage-continuity risks for VBC organizations managing Medicaid populations and safety-net partnerships. Meanwhile, CMS’ proposed 2027 OPPS/ASC update offers only a modest 2.4% base increase that could be offset by broader policy changes, reinforcing margin pressure for systems trying to fund ambulatory transformation and risk-based care infrastructure HFMA Health Affairs
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