Payment Integrity & Revenue Cycle
Expert articles and analysis related to payment integrity & revenue cycle.
AI Summary — Last 30 Days
Payment integrity pressure is intensifying across value-based care, with DOJ/CMS enforcement targeting Medicare Advantage risk-adjustment coding—most notably Complete Health’s $14M False Claims Act settlement—signaling that VBC enablement and primary care groups face growing exposure if documentation, diagnosis capture, and coding governance are not tightly controlled. At the same time, CMS transparency requirements are exposing wide variation in prior authorization denial rates across MA, Medicaid managed care, and ACA plans, creating new reputational and contracting risks for payers while giving providers and ACOs better leverage to challenge utilization-management friction. Medicaid financing is also becoming less predictable: KFF estimates that new 2025 reconciliation-law limits could reduce up to $60B in federal Medicaid state directed payments for hospital services, pressuring health systems to reassess Medicaid-dependent VBC economics, supplemental-payment assumptions, and payer-provider integration strategies.
Related Articles
Novitas Improperly Paid Millions for Medicare Part B Services for Nursing Home Patients
DOJ Charges 19 In Alleged $4M Medicaid, Medicare At-Home Care Fraud Scheme
New data on No Surprises Act IDR cases show providers won often in 2025
Providers and their intermediaries continued to flourish in the No Surprises Act’s independent dispute resolution (IDR) process during the second half of 2025, according to newly released data from th...
Complete Health to pay $14M to settle Medicare Advantage fraud allegations
The value-based primary care provider submitted false diagnosis codes to the CMS for three years, inflating its reimbursement by millions of dollars, according to the DOJ.
UnitedHealthcare to tighten reimbursement for lab tests
UnitedHealthcare to tighten reimbursement for lab tests Becker's Hospital Review
Medicare Advantage Provider Complete Health to Pay $14,100,000 to Settle False Claims Act Suit - Office of Inspector General (.gov)
Medicare Advantage Provider Complete Health to Pay $14,100,000 to Settle False Claims Act Suit Office of Inspector General (.gov)
United States: Medicare Advantage Provider Complete Health To Pay $14,100,000 To Settle False Claims Act Suit
United States: Medicare Advantage Provider Complete Health To Pay $14,100,000 To Settle False Claims Act Suit The St Kitts Nevis Observer
Two Additional Ophthalmology Practices Agree to Pay $2.3M to Resolve Allegations of Fraudulent Claims to Medicare and Medicaid for Cranial Ultrasounds - Office of Inspector General (.gov)
Two Additional Ophthalmology Practices Agree to Pay $2.3M to Resolve Allegations of Fraudulent Claims to Medicare and Medicaid for Cranial Ultrasounds Office of Inspector General (.gov)
Massachusetts Ophthalmology Practice to Pay Nearly $4 Million to Resolve False Claims Act Allegations - Office of Inspector General (.gov)
Massachusetts Ophthalmology Practice to Pay Nearly $4 Million to Resolve False Claims Act Allegations Office of Inspector General (.gov)
Two Additional Ophthalmology Practices Agree to Pay $2.3M to Resolve Allegations of Fraudulent Claims to Medicare and Medicaid for Cranial Ultrasounds - Department of Justice (.gov)
Two Additional Ophthalmology Practices Agree to Pay $2.3M to Resolve Allegations of Fraudulent Claims to Medicare and Medicaid for Cranial Ultrasounds Department of Justice (.gov)