Payment Integrity & Revenue Cycle
Expert articles and analysis related to payment integrity & revenue cycle.
AI Summary â Last 7 Days
CMS is tightening the operational and data transparency environment around prior authorization, with new requirements for MA, Medicaid managed care, and ACA marketplace plans aligning with payer and vendor moves to automate approvals through Epic, R1/Humata, and related APIsâraising the bar for VBC organizations to integrate authorization, claims, and clinical workflows rather than treat denials as back-end revenue cycle issues (HFMA). At the same time, payment integrity scrutiny is widening across MA, ACA, and Medicaid: the Monogram Health False Claims Act settlement, renewed House focus on MA data gaps, research on provider-sponsored insurersâ potential regulatory gaming, and Wakelyâs findings on supplemental claimsâ impact on ACA risk adjustment all point to a more contested environment for coding, risk adjustment, and taxpayer-funded payments (USC Schaeffer). For ACOs, MA-aligned providers, and payer-owned delivery assets, the weekâs through-line is clear: revenue optimization strategies increasingly must be defensible under transparency, audit, and fraud-and-abuse expectations, not just actuarially effective.
Related Articles
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United States: Medicare Advantage Provider Monogram Health Agrees to Pay $2.4M to Settle False Claims Act Suit  The St Kitts Nevis Observer
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Attorney General James Secures $6 Million from Three Buffalo Nursing Homes for Years-Long Fraudulent Billing Scheme - Office of Inspector General (.gov)
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Durable Medical Equipment: Protecting Medicare and Medicaid from Fraud, Waste, and Abuse - Office of Inspector General (.gov)
Durable Medical Equipment: Protecting Medicare and Medicaid from Fraud, Waste, and Abuse  Office of Inspector General (.gov)
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The Nationâs Challenge to Combat Durable Medical Equipment Fraud in Medicare  Office of Inspector General (.gov)
United States and State of Illinois File Complaint in Intervention in False Claims Act Lawsuit Against Chicago-Area Medical Practice and Billing Company for Allegedly Submitting Fraudulent Medicare and Medicaid Claims - oig.hhs.gov
United States and State of Illinois File Complaint in Intervention in False Claims Act Lawsuit Against Chicago-Area Medical Practice and Billing Company for Allegedly Submitting Fraudulent Medicare an...
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What are Modifiers and How Do You Use Them  AAPC