Revenue Cycle & Payment Integrity

CMS and enforcement agencies are tightening payment-integrity pressure across Medicare Advantage, DME, labs, and Medicaid: CMS blocked 11 medical supply companies tied to $3.4B in suspected fraudulent billing, while OIG exclusions and the Villages Health System risk-adjustment settlement reinforce that coding intensity, medical necessity, and supplier relationships are now core VBC compliance risks. At the same time, Medicaid financing is entering a more constrained phase, with OBBBA state-directed payment caps projected to materially reduce some states’ Medicaid spending, forcing health systems, ACO-adjacent provider networks, and managed care plans to revisit supplemental-payment assumptions and margin strategies. The throughline for VBC stakeholders is that “paying correctly” is becoming an operational mandate: risk adjustment, prior authorization/AI oversight, DME controls, and Medicaid payment design are converging into a tighter revenue-cycle environment where documentation discipline and defensible utilization management will matter as much as performance on quality and total cost of care.