Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary — Last 7 Days
In the last week, CMS initiated a freeze on enrollment in Elevance Health’s Medicare Advantage-Prescription Drug Plans due to serious noncompliance issues related to risk adjustment and data submission requirements, marking a significant enforcement action aimed at enhancing payment integrity in Medicare programs. Concurrently, a federal Medicaid audit uncovered $285.2 million in overpayments related to autism therapy in Colorado, illustrating ongoing concerns over fraud and improper payments in Medicaid. These developments underscore the Trump administration's commitment to a stringent oversight framework in healthcare, as outlined in President Trump's recent State of the Union address on March 4, 2025, where he emphasized increased focus on price transparency and program integrity efforts, such as the CRUSH initiative.
Related Articles
CRUSH and the New Era of Real-Time Program Integrity Oversight
EDITOR’S NOTE: The author of this article used AI-assisted tools in its composition, but all content, analysis, and conclusions were based on the author’s professional judgment and expertise. The arti...
The Other F Bomb in Healthcare: FRAUD (especially Medicaid)
40 minutes into the 108-minute State of the Union address Tuesday night, the President laid out his healthcare policy priorities for 2026 and after: Increased focus on price transparency (building... ...
HHS defers $259.5 million in Medicaid funding to Minnesota
A government "crackdown on healthcare fraud" includes a decision to defer $259.5 million of quarterly federal Medicaid funding to Minnesota to prevent payment of questionable claims while further inve...
6 Texas physicians to pay $5M to settle false claims allegations
Six South Texas physicians and their practices agreed to pay $4.9 million to resolve allegations they submitted false claims to Medicare, Medicaid and TriCare for services that were not rendered or no...
Balancing Policy, Safety, and Digital Care in Medication Use: Jody L. Green, PhD
CMS’ add-on billing code boosts specialist pay: Study
A new study published in JAMA found that a new Medicare add-on billing code boosted pay significantly for specialists. The study analyzed Medicare claims data from 2024, the first year that the G22111...
CMS freezes enrollment in Elevance Medicare Advantage-Part D plans
The Centers for Medicare and Medicaid Services is freezing enrollment in Elevance Health’s Medicare Advantage-Prescription Drug Plans for alleged noncompliance with risk adjustment and data submission...
The Conduent Breach: A Stewardship Failure at Scale
EDITOR’S NOTE: The author of this article used AI-assisted tools in its composition, but all content, analysis, and conclusions were based on the author’s professional judgment and expertise. The arti...
STAT+: Federal Medicaid audit finds massive overpayment for autism therapy in Colorado
HHS's OIG uncovered $285.2 million in improper and potentially improper payments to clinicians of an autism therapy called applied behavior analysis, it said.
CMS announces pause on new durable medical equipment suppliers
The Trump administration issued a nationwide moratorium on new suppliers for certain medical equipment, citing fraud.