Revenue Cycle Integrity
Expert articles and analysis related to revenue cycle integrity.
AI Summary — Last 30 Days
Revenue cycle integrity has become a front-line VBC risk issue as DOJ enforcement against Medicare Advantage risk adjustment intensifies, with Humana-owned The Villages Health agreeing to a roughly $542M settlement over alleged unsupported diagnosis coding from 2020–2024. The signal for ACOs, MA-aligned provider groups, and risk-bearing MSOs is that coding capture, encounter documentation, vendor oversight, and compliance governance are now strategic infrastructure—not back-office functions—especially as MedPAC continues scrutinizing plan-level MA risk-adjustment accuracy. In parallel, CMS prior-authorization transparency requirements are tightening plan accountability, increasing pressure on payers and delegated provider organizations to align utilization management, documentation, and appeals operations with auditable value-based payment performance.
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The Nation’s Challenge to Combat Durable Medical Equipment Fraud in Medicare - Office of Inspector General (.gov)
The Nation’s Challenge to Combat Durable Medical Equipment Fraud in Medicare  Office of Inspector General (.gov)
United States and State of Illinois File Complaint in Intervention in False Claims Act Lawsuit Against Chicago-Area Medical Practice and Billing Company for Allegedly Submitting Fraudulent Medicare and Medicaid Claims - oig.hhs.gov
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