Revenue Cycle Integrity
Expert articles and analysis related to revenue cycle integrity.
AI Summary — Last 7 Days
Revenue cycle integrity risk is intensifying around Medicare Advantage risk adjustment, with DOJ False Claims Act activity and a reported $541.5M settlement involving The Villages Health System reinforcing that diagnosis coding, chart review practices, and provider–payer incentive structures are now core VBC compliance exposure—not just back-office billing issues. MedPAC’s work on plan-level MA risk adjustment accuracy adds policy pressure to the same fault line, as CMS and policymakers scrutinize whether coding intensity is distorting benchmarks, rebates, and shared-savings economics. At the same time, wide variation in prior authorization denials signals a parallel revenue-cycle integrity challenge for providers and ACOs: success in risk-based contracts increasingly depends on auditable coding governance, defensible medical necessity documentation, and tighter alignment between utilization management and population health workflows.
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CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only - Office of Inspector General (.gov)
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OIG: Medicare Part D plans spent millions on ineligible drugs
OIG: Medicare Part D plans spent millions on ineligible drugs Fierce Healthcare
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. - 24/7 Wall St.
For 4 Years, The Villages' Top Health Provider Allegedly Filed False Medicare Codes. The Bill Just Came Due: $541.5 Million. 24/7 Wall St.
Conflicting CMS Guidance and Federal Statutory Requirements Cost Medicare $380 Million Over a 6-Year Period for Organs Not Transplanted Into Medicare Enrollees - oig.hhs.gov
Conflicting CMS Guidance and Federal Statutory Requirements Cost Medicare $380 Million Over a 6-Year Period for Organs Not Transplanted Into Medicare Enrollees oig.hhs.gov
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Medicare spent hundreds of millions of dollars on ineligible drugs, audit finds
Shoddy CMS oversight is to blame, and the agency needs to do better, the HHS Office of the Inspector General said. The CMS concurred.
CMS Oversight Did Not Prevent Medicare Part D Sponsors From Making $587.7 Million in Ineligible Payments to Pharmacies for Drugs Available Over the Counter but Labeled as Prescription-Only - Office of Inspector General (.gov)
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The State of Post-Payment Risk: How Healthcare Organizations Are Responding to Growing Payer Complexity
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