Payment Integrity
Expert articles and analysis related to payment integrity.
AI Summary — Last 7 Days
Payment integrity activity is converging around tighter utilization management, managed care oversight, and AI-enabled billing risk: CMS’s WISeR prior authorization model and DMEPOS prior auth changes signal continued federal testing of pre-payment controls, while stakeholders such as AMA are pressing CMS to preserve electronic prior authorization timelines to reduce administrative friction in care delivery. At the same time, Medicare Advantage and Medicaid managed care are facing renewed scrutiny over coding, medical loss ratio accuracy, and False Claims Act exposure, reinforcing that risk-bearing entities will need stronger documentation, encounter-data governance, and compliance controls as VBC payment models mature. CMS Administrator Dr. Mehmet Oz’s warning that AI could “turbocharge” billing before lowering costs underscores a near-term tension for ACOs, MA plans, and providers: technology may improve care management and payment accuracy, but it could also amplify overbilling and utilization unless paired with robust payment integrity infrastructure ([WISeR hospital impact](https://news.google.com/rss/articles/CBMimwFBVV95cUxQdExPUWFrS013S1M0RDBUNUd6dm1NcE1aS19lOGpPQnptdFVudFhGWTVQNTRmMkhoTzVfVm9IT2NPTC1MMjE5cUZHQ2JlbFBURDFnWTkwQVNLMmhEODA2VWczcDJSaklvWHlkWTNQUkpx
Related Articles
CMS cites ACA marketplace enrollment fraud in issuing 760,000 coverage cancellations
CMS has canceled roughly 315,000 enrollments encompassing 760,000 people in Affordable Care Act (ACA) marketplace plans, citing suspected fraud, according to a Sept. 22 announcement by the Trump admin...
How to combat the insurer payment delays that are destabilizing independent medicine
How to combat the insurer payment delays that are destabilizing independent medicine Fierce Healthcare
Texas Mental Health Clinic Owner Convicted in $26M Scheme to Defraud Military Health Benefits Program - Department of Justice (.gov)
Texas Mental Health Clinic Owner Convicted in $26M Scheme to Defraud Military Health Benefits Program Department of Justice (.gov)
AG Campbell Announces $1 Million Settlement With Nursing Facility Operator RegalCare For Medicare And Medicaid Price Hike Scheme - oig.hhs.gov
AG Campbell Announces $1 Million Settlement With Nursing Facility Operator RegalCare For Medicare And Medicaid Price Hike Scheme oig.hhs.gov
Chief Operating Officer Pleads Guilty for Role in $500M COVID-19 Test Billing Fraud - oig.hhs.gov
Chief Operating Officer Pleads Guilty for Role in $500M COVID-19 Test Billing Fraud oig.hhs.gov
Tennessee Claimed Federal Medicaid Reimbursement for Millions of Dollars in Targeted Case Management Services That Did Not Comply With Federal and State Requirements - oig.hhs.gov
Tennessee Claimed Federal Medicaid Reimbursement for Millions of Dollars in Targeted Case Management Services That Did Not Comply With Federal and State Requirements oig.hhs.gov
CMS targets unauthorized marketplace enrollments, seeks $2.2B
CMS targets unauthorized marketplace enrollments, seeks $2.2B Healthcare Finance News
‘They steal the nation’s trust’: Dr. Oz on why fraud detection can’t wait
‘They steal the nation’s trust’: Dr. Oz on why fraud detection can’t wait Becker's Hospital Review
New York Made Unallowable Managed Care Capitation Payments on Behalf of Incarcerated Medicaid Enrollees - Office of Inspector General (.gov)
New York Made Unallowable Managed Care Capitation Payments on Behalf of Incarcerated Medicaid Enrollees Office of Inspector General (.gov)