Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary — Last 7 Days
Payment integrity pressure in Medicare Advantage intensified this week as DOJ scrutiny of risk-adjustment practices escalated around Elevance executive access and Aetna agreed to a $117.7M false-claims settlement—reinforcing that MA coding, RAF/HCC documentation, and chart-review operations remain high-risk areas for VBC organizations and payer partners. At the same time, Congress is targeting MA prior authorization and denial practices, while provider-side disputes over CMS auditing of SNF rehab access after surgery show payment integrity is increasingly colliding with care-access and discharge-planning realities across MA, bundled payments, and post-acute networks. The through-line for ACOs, health systems, and plans: compliance infrastructure around coding, utilization management, and post-acute medical necessity is becoming as strategically important as performance on cost and quality. [Aetna MA false-claims settlement](https://news.google.com/rss/articles/CBMi_AJBVV95cUxNWWxVUXp2cEprZjNNQzk1MXN6WjA2Z3paZGRIUzRKU2lCOUc4WjhPcDdvLWpWQ0VhYjNNYlBqMlVoT1YzdnpTdm9LYlNLMEwydVl5Q3psX3dRSF9GZG9yQnV1WWptY3ZIVDNwZjJyS3VJbUpLUGJr
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