Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary ā Last 30 Days
Payment integrity is moving from retrospective audits to a more active operating model in Medicare, with the Trump administrationās CMS defending the WISeR AI prior authorization test even as Senate Democrats failed to repeal it, signaling continued experimentation with tech-enabled utilization controls in traditional Medicare. At the same time, enforcement risk is rising for VBC and Medicare Advantage-aligned primary care groups after Complete Health agreed to pay $14.1 million to settle allegations it submitted unsupported diagnosis codes that inflated MA risk-adjustment paymentsāreinforcing that coding intensity, documentation governance, and vendor/physician incentives remain core strategic risks for ACOs, MA providers, and risk-bearing platforms. Together, WISeRās survival and the Complete Health settlement point to a tighter federal posture: CMS is pursuing savings through both prospective utilization management and retrospective False Claims Act enforcement, raising the bar for clinical appropriateness, documentation integrity, and compliance infrastructure in value-based care.
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