Revenue Cycle Integrity
Expert articles and analysis related to revenue cycle integrity.
AI Summary â Last 30 Days
Revenue cycle integrity in Medicare is shifting from retrospective coding/payment disputes to more automated front-end utilization control, as the Trump administrationâs CMS advances the WISeR AI prior authorization pilot while Senate Republicans blocked an effort to repeal itâintensifying 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).
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.
Medicare Advantage organizations are denying some post-acute care at high rates
Medicare Advantageâs prior authorization process is still a âWild West,â one expert says.
NACDS Urges CMS to Make Pharmacies Central to Modernizing Prior Authorization and Advancing Interoperability
In comments to the agency, NACDS calls for reforms that work within real-world pharmacy workflows â reducing the administrative burdens that delay patients' access to their medications. NACDS' consis...
Prior authorization reform gets promising start from House health panel
Prior authorization reform gets promising start from House health panel  American Medical Association
OIG flags Pennsylvania behavioral insurer for faulty prior auth denials
What Upstream Prior Authorization Denials Mean for Home Health Providers
Elevance Health pays $342M to government in midst of billing probe
Elevance Health pays $342M to government in midst of billing probe  Fierce Healthcare
Medicare Advantage Company Pays $342M to Government in Midst of Billing Probe
The payment by Elevance Health to the Centers for Medicare & Medicaid Services comes as the agency threatened to bar new enrollments in the companyâs plans.