Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary — Last 30 Days
Payment integrity is moving from retrospective cleanup to a central design constraint in Medicare VBC strategy: CMS is tightening Medicare Advantage economics through the 2027 MA rate announcement, RADV extrapolation risk, star-rating recalculations, and OIG scrutiny of MA prior authorization and risk-adjustment practices, raising the stakes for plans, delegated risk groups, and ACO-aligned providers that depend on accurate coding and bonus revenue. At the same time, the Trump administration’s WISeR AI prior authorization pilot is drawing bipartisan resistance in Congress, signaling a growing tension between using automation to reduce improper payments and protecting beneficiary access in post-acute and high-cost services (House committee action on WISeR). For health systems and VBC organizations, the strategic priority is shifting toward auditable documentation, defensible HCC capture, utilization-management transparency, and scenario planning for MA revenue volatility as CMS and OIG narrow perceived MA payment advantages (HFMA on MA payment advantage).
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