Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary — Last 7 Days
Payment integrity pressure intensified across Medicare Advantage, Medicaid, and model design: CMS’ recalculation of MA Star Ratings after litigation adds revenue volatility to bonus payments while OIG’s MA industry guidance, scrutiny of post-acute prior authorization denials, and Premier’s focus on HCC documentation accuracy point to tighter oversight of risk adjustment, utilization management, and coding practices. At the same time, DOJ’s $6.5B healthcare fraud takedown and allegations involving Medicaid funds in New York home care signal a broader Trump administration crackdown.
Related Articles
Hospitals irate after Eli Lilly follows through on 340B ultimatum
The drugmaker stopped paying 340B discounts to hospitals that didn’t comply with its new paperwork requirements late last week. Hospitals are urging HRSA to step in.
FTC Takes Action to Protect Americans from Higher Drug Costs in Aurobindo, Lannett Deal - Federal Trade Commission (.gov)
FTC Takes Action to Protect Americans from Higher Drug Costs in Aurobindo, Lannett Deal Federal Trade Commission (.gov)
PCMA sues to exempt PBMs from Illinois drug law
The drug middlemen lobby has had a busy week. It’s the second major lawsuit the PCMA has filed against a state law reforming the PBM industry since Monday.
Hospitals Cry Foul After Eli Lilly Withholds 340B Discounts
Hospitals Cry Foul After Eli Lilly Withholds 340B Discounts MedCity News
Trump targets Germany over drug prices: 5 notes
Trump targets Germany over drug prices: 5 notes Becker's Hospital Review
Philip Sclafani: Will PBM Reform Actually Lower Net Drug Costs?
Philip Sclafani: Will PBM Reform Actually Lower Net Drug Costs? Pharmaceutical Commerce
Approved but Underpaid: How Payers are Quietly Redrawing the Rules of Hospital Reimbursement
The following is a guest article by Missy Harbert, Senior Solution Advisor at Revecore For years, hospitals have built denial management programs around a predictable premise: when a payer disputes a ...
US government launches probe into Germany's plan to pay less for drugs
Amid Germany's ongoing review of its healthcare spending, the US government has started a trade investigation into the European country's drug pricing system. The investigation, under Section 301 of...
Eli Lilly begins denying 340B discounts
Eli Lilly begins denying 340B discounts Becker's Hospital Review
STAT+: Eli Lilly ends 340B drug discounts to some hospitals for failing to provide claims data
Making good on its threat, Eli Lilly has begun eliminating mandated price breaks to a few dozen hospitals that participate in a federal drug discount program.