Risk Adjustment & Integrity
Expert articles and analysis related to risk adjustment & integrity.
AI Summary — Last 30 Days
CMS is tightening the financial and data-integrity environment around value-based care: Medicare Advantage plans face intensifying RADV extrapolation and payment scrutiny, while the 2027 MA rate process signals a push to narrow MA’s perceived payment advantage over traditional Medicare, raising the stakes for coding governance, documentation, and bid strategy (HFMA). At the same time, ACO strategy is shifting toward more sophisticated downside-risk management as MSSP and the CMS Innovation Center’s LEAD Model expand the need for stop-loss, risk modeling, and convener-enabled scale—creating a sharper divide between organizations with actuarial infrastructure and those exposed to unmanaged benchmark and claims volatility (Wakely). Congressional pushback against CMS’s Medicare AI prior authorization pilot adds another integrity-versus-access tension: policymakers are scrutinizing algorithmic utilization management even as CMS leadership under the Trump administration emphasizes technology-enabled oversight and program savings.
Related Articles
The AI arms race in the revenue cycle
Hospitals are combatting payer claim denials by deploying AI in the revenue cycle, concentrating on coding and documentation in the mid-cycle.Payers have been using AI algorithms to automate claims pr...
CMS moves to curb MA plans’ unfair payment advantage
In April, CMS published its annual Medicare Advantage (MA) rate announcement for 2027.a For most years in recent memory, this would be a routine event, accompanied by no small amount of headshaking fr...
HLB’s Fraud & Abuse Blog | Hooper Lundy & Bookman
Justice Department can question former Elevance exec in Medicare Advantage fraud case, judge rules
CMS Targets State Payment Loopholes to Strengthen Medicaid Integrity
Prevent denials by catching credentialing issues
Verifying the credentials of ordering physicians should be an essential part of revenue cycle management, and it could prove to be a fruitful endeavor. Ximena Restrepo, compliance and privacy partner ...
Massachusetts behavioral health clinics to pay $1.4M to settle fraud allegations
Judge dismisses BCBS Texas’ surprise billing lawsuit against HaloMD
It’s the fourth federal court in six weeks to reject insurer attempts to relitigate No Surprises determinations, HaloMD said. The dismissals have thrown cold water on insurers’ efforts to contest alle...
When Lower Cost-to-Collect Fails to Improve Healthcare Organization Cash
The following is a guest article by Sid Mehta, President and Chief Growth Officer at Access Healthcare Why yield is the difference between operating efficiently and getting paid correctly Cost-to-coll...
APRN charged in $1.35M Medicare fraud scheme
A Florida woman and former Connecticut advanced practice registered nurse has been arrested on charges of submitting more than $1.35 million in fraudulent Medicaid claims for medication management ser...