Payment Integrity & RCM
Expert articles and analysis related to payment integrity & rcm.
AI Summary — Last 30 Days
CMS payment-integrity pressure is intensifying around Medicare Advantage, with coding-intensity scrutiny, RADV extrapolation risk, star-ratings disputes, and legislative proposals to reduce MA overpayments converging into a more adversarial revenue environment for plans—and indirectly for VBC providers dependent on MA risk revenue. At the same time, the Trump administration’s WISeR Medicare AI prior authorization pilot is becoming a flashpoint as lawmakers challenge whether automated utilization management will reduce improper spending or simply delay care, especially for post-acute services where MA denial rates are already substantially higher and often overturned on appeal. For ACOs, MA risk-bearing groups, and health systems, the strategic implication is clear: documentation, risk adjustment governance, prior-auth operations, and post-acute discharge planning are becoming core VBC infrastructure, not back-office RCM functions (KFF on MA coding intensity; KFF on MA post-acute prior authorization denials).
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