Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary — Last 24 Hours
CMS is intensifying payment-integrity enforcement across Medicaid, ACA Marketplaces, and value-based payment operations: an Aug. 11 final rule bars federal Medicaid/CHIP matching funds for gender-affirming care for minors, while HHS/CMS actions to identify potentially unauthorized ACA Marketplace enrollments could drive significant issuer disenrollments and risk-adjustment volatility. For VBC stakeholders, the most immediate operational signal is that CMS is requesting updated billing information from qualifying Advanced APM participants to disburse incentive payments, reinforcing that model participation revenue now depends on clean provider/payment data and tighter federal validation. At the same time, courts struck down the No Surprises Act payment methodology, creating near-term uncertainty for payer-provider reimbursement dynamics that can spill into network strategy, shared-savings economics, and out-of-network exposure (AHA on APM billing updates
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