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Risk adjustment is facing intensified regulatory scrutiny with the combined impact of recent updates from CMS, planned RADV audit expansion, and OIG and DOJ enforcement priorities. With greater exposure to potential liabiliti...


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Healthcare organizations process enormous volumes of encounter data every day. Across Medicare, Medicaid, and ACA programs, encounter submissions move through complex pipelines that involve ...


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Fraud, waste, and abuse (FWA) schemes involving diagnostic testing continue to evolve, often leveraging complex coverage rules and aggressive outreach practices. Colon cancer screening kits, while clinically valuab...


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The recently released 2027 Medicare Advantage (MA) and Part D Final Rule confirms changes that many MA quality leaders were anticipating: the pace of change in the Star Ratings program is not slowin...


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