Compliance & Payment Integrity
Expert articles and analysis related to compliance & payment integrity.
AI Summary — Last 30 Days
Payment integrity is becoming a defining constraint on VBC strategy as CMS, DOJ, and plans intensify scrutiny of Medicare Advantage risk adjustment, audit readiness, Stars disputes, and AI-enabled utilization controls; recent settlements and fraud litigation around MA coding practices are reinforcing that documentation infrastructure must support both revenue accuracy and defensible compliance. At the same time, AI is being positioned as both a solution and a risk vector: vendors are marketing more “ethical” risk adjustment and audit platforms, while reports of Medicare AI prior authorization delays in Washington raise access and provider-burden concerns that could shape how CMS governs automation in payment models and care management (AI prior authorization delays). Medicaid drug-cost innovation is also moving into the payment-integrity frame, with the GENEROUS model’s savings potential dependent on confidential operational details and state/federal implementation choices—important for ACOs and risk-bearing organizations exposed to pharmacy trend, affordability metrics, and total-cost benchmarks (KFF on GENEROUS).
Related Articles
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Columbia, Missouri Doctor Arrested, Accused of Health Care Fraud, Illegally Prescribing Drugs Office of Inspector General (.gov)
Eye Practice and Physician Owner Agree to Pay $415,000 to Resolve Allegations of False Claims Act to Medicare - Office of Inspector General (.gov)
Eye Practice and Physician Owner Agree to Pay $415,000 to Resolve Allegations of False Claims Act to Medicare Office of Inspector General (.gov)
STAT+: CMS to ask every state for new audits of health care providers
The Trump administration has been heavily focused on combating purported fraud in federal health care programs.
The Next Era of Payment Integrity: Earlier Clinical Validation, True Transparency
The Next Era of Payment Integrity: Earlier Clinical Validation, True Transparency MedCity News
Former Pharmacy President Sentenced to 24 Months in Prison for Health Care Fraud and Kickback Scheme Involving Compounded Medications - Office of Inspector General (.gov)
Former Pharmacy President Sentenced to 24 Months in Prison for Health Care Fraud and Kickback Scheme Involving Compounded Medications Office of Inspector General (.gov)
New Federal Focus on Fraud, Waste and Abuse May Signal Changes for the Health Care Industry
Metro Detroit Surgeon Was Sentenced to a Year in Prison in $7 Million Dollar Medicare Fraud Scheme - Office of Inspector General (.gov)
Metro Detroit Surgeon Was Sentenced to a Year in Prison in $7 Million Dollar Medicare Fraud Scheme Office of Inspector General (.gov)
Six St. Louis Area Residents Accused of $8.3 Million Pandemic Fraud - Office of Inspector General (.gov)
Six St. Louis Area Residents Accused of $8.3 Million Pandemic Fraud Office of Inspector General (.gov)
CMS Has Limited Oversight of Selected Compounded Drugs Prescribed to Medicare Part D Enrollees - Office of Inspector General (.gov)
CMS Has Limited Oversight of Selected Compounded Drugs Prescribed to Medicare Part D Enrollees Office of Inspector General (.gov)
Attorney General Raúl Torrez Announces $6.6 Million Restitution for Mother-Daughter Duo Leading Afterschool Program Medicaid Fraud and Child Identity Theft Scheme - Office of Inspector General (.gov)
Attorney General Raúl Torrez Announces $6.6 Million Restitution for Mother-Daughter Duo Leading Afterschool Program Medicaid Fraud and Child Identity Theft Scheme Office of Inspector General (.gov)