Revenue Cycle Integrity

Revenue cycle integrity in Medicare is shifting from retrospective coding/payment disputes to more automated front-end utilization control, as the Trump administration’s CMS advances the WISeR AI prior authorization pilot while Senate Republicans blocked an effort to repeal it—intensifying the tension between payment accuracy, administrative burden, and beneficiary access in traditional Medicare. At the same time, Medicare Advantage remains under pressure from coding-intensity scrutiny, Star Ratings litigation, and diagnosis-validation disputes, underscoring that VBC organizations will need tighter documentation governance, audit readiness, and prior authorization operating models as CMS and plans push harder on risk-adjusted payment integrity and utilization management (WISeR Senate vote; MA coding intensity).