Payment Integrity & Utilization

Payment integrity pressure intensified across Medicare Advantage and utilization management: HHS OIG audits alleged HumanaChoice and UnitedHealthcare of Wisconsin submitted unsupported diagnosis codes that produced nearly $180 million in overpayments, reinforcing DOJ/FCA scrutiny of MA risk-adjustment coding programs and raising compliance stakes for payers, delegated groups, and VBC providers tied to coding capture. At the same time, CMMI Director Abe Sutton positioned the WISeR Medicare prior authorization model as a template for broader federal use even as reporting pointed to launch delays, tech failures, and provider concerns—signaling that CMS is pursuing AI-enabled utilization controls while operational reliability and care access remain major flashpoints for ACOs and specialty networks (OIG MA audit coverage; WISeR model direction).