Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary — Last 30 Days
Payment integrity is shifting from retrospective recovery to prospective utilization and coding control: HHS OIG audits of HumanaChoice and UnitedHealthcare of Wisconsin found MA diagnosis-code submissions driving nearly $180 million in alleged overpayments, while the $541.5 million Villages Health settlement signals escalating False Claims Act risk for provider organizations participating in MA risk-adjustment workflows (Healthcare Dive). At the same time, CMMI under Abe Sutton is positioning the WISeR prior authorization model as a template for broader Medicare payment-integrity interventions, creating a strategic tension for ACOs and VBC providers between reducing low-value care and absorbing new administrative, documentation, and technology burdens (HFMA). For payers and risk-bearing providers, the through-line is clear: coding accuracy, evidence-backed diagnoses, and defensible utilization management are becoming core operating capabilities—not back-office compliance functions.
Related Articles
The Next Era of Payment Integrity is Prevention, Not Recovery
The following is a guest article by Anne Neal, Vice President of Product Management for Payment Accuracy at Availity As Payment Integrity Programs Face Rising Administrative and Provider Friction, the...
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only - Office of Inspector General (.gov)
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only Office of ...
From reactive denial management to upstream prevention
Denials are usually discovered after adjudication. The revenue loss, however, often begins much earlier. Hospitals continue to invest significant time and resources in denial management, yet roughly 1...
7 Medicare Fraud Red Flags Seniors Should Watch for After CMS Blocked $1.6 Billion in Payments - savingadvice.com
7 Medicare Fraud Red Flags Seniors Should Watch for After CMS Blocked $1.6 Billion in Payments savingadvice.com
OIG: Medicare Part D plans spent millions on ineligible drugs
OIG: Medicare Part D plans spent millions on ineligible drugs Fierce Healthcare
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. - 24/7 Wall St.
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. 24/7 Wall St.
Conflicting CMS Guidance and Federal Statutory Requirements Cost Medicare $380 Million Over a 6-Year Period for Organs Not Transplanted Into Medicare Enrollees - oig.hhs.gov
Conflicting CMS Guidance and Federal Statutory Requirements Cost Medicare $380 Million Over a 6-Year Period for Organs Not Transplanted Into Medicare Enrollees oig.hhs.gov
Catching Errors Before Claims Go Out: How Mature Home Health Agencies Prevent Billing Mistakes
Medicare spent hundreds of millions of dollars on ineligible drugs, audit finds
Shoddy CMS oversight is to blame, and the agency needs to do better, the HHS Office of the Inspector General said. The CMS concurred.
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only - Office of Inspector General (.gov)
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only Office of ...