Risk Adjustment & Integrity
Expert articles and analysis related to risk adjustment & integrity.
AI Summary — Last 24 Hours
CMS is moving on Medicare Advantage oversight with proposals targeting provider directory accuracy and PBM transparency, signaling continued Trump administration pressure on MA plans to tighten beneficiary access representations, drug-cost accountability, and downstream data integrity that affects risk adjustment and Star Ratings. At the same time, prior authorization reform is converging with interoperability: API-enabled PA is being positioned as a way to reduce blunt utilization management while preserving plan controls—an immediate operational issue for MA plans, ACO-aligned providers, and vendors managing documentation, coding, and care transitions (AHA on CMS proposals, Healthcare IT News on prior auth APIs). HHS OIG’s latest sentencing in a nearly $900,000 fraud case reinforces the enforcement backdrop: VBC organizations should expect risk adjustment, coding, network adequacy, and utilization-management data to face increasing scrutiny as CMS links payment accuracy with program integrity.
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Two Florida defendants sentenced to prison for nearly $900,000 health care scam - Office of Inspector General (.gov)
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