Revenue-Cycle, Payment-Fraud, Risk-Adjustment, and Reimbursement Enforcement Intensify

DOJ and HHS announced a six-month civil FCA self-disclosure pilot, with an April 22, 2027 deadline and reported repayment terms of 1.25–1.6 times the base amount; participants must weigh civil disclosure against criminal and whistleblower exposure. HHS OIG findings, Complete Health’s $14.1 million Medicare Advantage settlement, OIG Advisory Opinion 26-16, and enforcement messaging reinforce financial, inducement, False Claims Act, DMEPOS, and supplier-screening exposure. October 20 NYC adult day-care raids remain allegations, and CMS’s reported authority over certain permissive exclusions has unclear implementation details; sustain risk-based audits, physician review, appeals, audit trails, repayment processes, and vendor accountability.