Program Integrity Oversight
Expert articles and analysis related to program integrity oversight.
AI Summary â Last 30 Days
Program integrity oversight is tightening across Medicare payment channels: CMS is testing AI-enabled prior authorization in traditional Medicare through WISeR while lawmakers press for more transparency on whether the model delays care, and Medicare Advantage remains under scrutiny over coding intensity, home-visit diagnoses, Star Ratings methodology, and risk-adjustment accuracy. For VBC stakeholders, the strategic signal is that payment model growth will increasingly be paired with auditability, documentation discipline, and data infrastructureâespecially as CMMIâs financial impact and Medicare Trust Fund reporting gaps draw attention (Avalere) and MA coding practices face renewed policy scrutiny (KFF). Medicaid financing is also entering a tougher oversight cycle, with CMSâs provider tax proposed rule threatening major supplemental payment reductions, raising downstream risk for health systems and ACO-adjacent population health strategies dependent on Medicaid cross-subsidization.
Related Articles
Statement on House Subcommittee Approval of the Improving Seniorsâ Access to Timely Care Act
Premier applauds the House Energy and Commerce Health Subcommittee for advancing bipartisan legislation to modernize prior authorization for Medicare Advantage patients.
Democrats push for more data on Medicare AI prior authorization pilot
The letter to the CMS from Democrats is the latest salvo from lawmakers concerned that WISeR is delaying care to Medicare beneficiaries.
Nationwide Analysis of Antipsychotic Drug Use in Nursing Homes - Office of Inspector General (.gov)
Nationwide Analysis of Antipsychotic Drug Use in Nursing Homes  Office of Inspector General (.gov)
Donât Celebrate the Wrong Win: What CMS-0053-F Actually Changes
Donât Celebrate the Wrong Win: What CMS-0053-F Actually Changes  MedCity News
West Virginia Changes Prior Authorization Law After Man's Treatment Delay and Death
West Virginia Changes Prior Authorization Law After Man's Treatment Delay and Death  AJMC
Why Midterms, CMS Precedent Signal Extension To Home Health Enrollment Moratorium
OIG Reveals Cardiovascular Testing Scam
OIG Issues RFI on Anti-Kickback Statute Safe Harbors for Clinical Trial Participant Remuneration â Comments Due August 24, 2026
The U.S. Department of Health and Human Services (âHHSâ) Office of Inspector General (âOIGâ) has issued a meaningful Request for Information (âRFIâ) seeking stakeholder input on potential new or modif...
U.S. Attorney Announces $2.2 Million Settlement With Urologists For Submitting False Claims To Medicare - Office of Inspector General (.gov)
U.S. Attorney Announces $2.2 Million Settlement With Urologists For Submitting False Claims To Medicare  Office of Inspector General (.gov)
Prior authorization reform gets promising start from House health panel
Prior authorization reform gets promising start from House health panel  American Medical Association