Payment Integrity

CMS’s conditional approval of Florida’s Medicaid state-directed payment program signals continued federal tolerance for large provider-directed Medicaid payment flows, but it keeps payment integrity tensions front and center for ACOs, hospitals, and Medicaid managed care plans that must reconcile supplemental funding with quality, access, and actuarial soundness requirements (Washington Post via HTN). In Medicare Advantage, scrutiny of Humana’s rapid membership growth and Devoted’s reported request for CMS to reduce its payment underscores a sharper risk-adjustment and coding-integrity environment where growth strategies are being tested.