Payment Integrity & RCM
Expert articles and analysis related to payment integrity & rcm.
AI Summary — Last 7 Days
Payment integrity scrutiny is intensifying around Medicare Advantage, with renewed focus on coding-intensity-driven overpayments, post-acute prior authorization denials, and the fiscal impact of proposals like the Saving MEDICARE Act—raising stakes for MA plans, ACOs, and VBC organizations that rely on risk adjustment and post-acute network performance. The emerging tension is that CMS under the Trump administration is pushing harder on payment accuracy and technology-enabled oversight, while plans are contesting revenue impacts, including Elevance’s $115M star ratings lawsuit, and providers face operational risk from delayed or denied SNF, IRF, and LTCH authorizations that are often overturned on appeal. For VBC stakeholders, the week’s signal is clear: risk adjustment defensibility, documentation integrity, and post-acute utilization management are becoming central compliance and margin priorities, not back-office functions (KFF on MA coding intensity; KFF on post-acute prior authorization denials).
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