Payment Integrity & RCM
Expert articles and analysis related to payment integrity & rcm.
AI Summary — Last 24 Hours
Payment integrity pressure is intensifying across Medicare Advantage, ACA exchanges, Medicaid, and outpatient hospital payment: KFF reports MA plans are denying prior authorization for post-acute care—LTCH, IRF, and SNF stays—at substantially higher rates than overall requests, with many denials overturned on appeal, raising discharge-delay and care-continuity risks for ACOs and hospitals managing frail beneficiaries under total-cost-of-care contracts (KFF). CMS also faces payer pushback as Elevance sues over a $115M Medicare Advantage Star Ratings dispute, while exchange insurers owe $11.2B in ACA risk-adjustment payments—signaling that risk adjustment, quality scoring, and coding defensibility remain major revenue and compliance battlegrounds for payers and VBC entities. On the enforcement side, HHS OIG’s telehealth claims analytics toolkit and decertification of New York’s Medicaid Fraud Control Unit reinforce a CMS and HHS oversight posture that will likely increase scrutiny of documentation, coding, utilization management, and virtual-care claims integrity across Medicare and Medicaid programs.
Related Articles
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks - Office of Inspector General (.gov)
Toolkit: Analyzing Telehealth Claims to Assess Program Integrity Risks  Office of Inspector General (.gov)
Statement on Federal Decertification of the New York Medicaid Fraud Control Unit - Office of Inspector General (.gov)
Statement on Federal Decertification of the New York Medicaid Fraud Control Unit  Office of Inspector General (.gov)
KLAS Emerging Company Spotlight: Enhancing risk adjustment coding defensibility through neuro-symbolic AI solutions
See the grades RAAPID's customers gave in the 2026 KLAS Emerging Company Spotlight.
3 revenue cycle investments that paid off faster than expected
3 revenue cycle investments that paid off faster than expected  Becker's Hospital Review
Schweikert Joins Fox Business to Discuss SAVE Act, Federal Spending and Health Care Fraud - Congressman Schweikert (.gov)
Schweikert Joins Fox Business to Discuss SAVE Act, Federal Spending and Health Care Fraud  Congressman Schweikert (.gov)
KLAS Emerging Company Spotlight: Enhancing risk adjustment coding defensibility through neuro-symbolic AI solutions
KLAS Emerging Company Spotlight: Enhancing risk adjustment coding defensibility through neuro-symbolic AI solutions  Healthcare Dive
PPL Reaches Proposed $162M Settlement With NY CDPAP Caregivers
Exchange insurers owe $11.2B in ACA risk-adjustment payments
Exchange insurers owe $11.2B in ACA risk-adjustment payments  Modern Healthcare
Copay Assistance Is Meant To Defray Patient Drug Costs. Some Insurers Keep It Instead.
Drugmakers provide financial assistance to help patients afford increasingly expensive medications. But some insurers do not count those payments toward a plan’s deductible or out-of-pocket maximum an...
STAT+: This whistleblower took on a health insurance giant and a political machine. She’s not stopping there
America’s employers must stop acting helpless in the face of health care industry profiteering, Chris Deacon says.