Policy / Regulatory Changes
Signals classified into this topic vertical.
235 signals
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8 recent Medicare Advantage contract suspensions, terminations
CMS has taken a series of enforcement actions against Medicare Advantage plans over the last two years, suspending enrollment and terminating contracts over issues ranging from network adequacy to financial solvency failures. Eight updates: The post 8 recent Medicare Advantage contract suspensions, terminations appeared first on Becker's Payer Issues | Payer News .
Policy / Regulatory Changes · 67 signals · last 30 days -
Medicare paid estimated $380M for unused organs: OIG
Over a six-year period, Medicare may have spent $380 million on organs that were not ultimately used in covered enrollee transplants, according to a September HHS Office of Inspector General report. Under federal law, Medicare can only reimburse certified transplant centers for organs used in covered transplants. However, CMS guidance relies on the assumption that […] The post Medicare paid estimated $380M for unused organs: OIG appeared first on Becker's Payer Issues | Payer News .
Policy / Regulatory Changes · 67 signals · last 30 days -
CMS rebrands ICHRA
CMS has rebranded individual coverage health reimbursement arrangements to CHOICE Arrangements, or Custom Health Option and Individual Care Expense. The new name for the alternative health insurance model was announced Sept. 3 by CMS Administrator Mehmet Oz, MD, at an event in Indiana. ICHRAs let employers give workers a fixed, tax-free amount to buy their […] The post CMS rebrands ICHRA appeared first on Becker's Payer Issues | Payer News .
Policy / Regulatory Changes · 67 signals · last 30 days -
OIG: Medicare Part D plans spent millions on ineligible OTC drugs
Medicare Part D plans made millions in payments for drugs that were ineligible under the program, according to a new federal audit.
Policy / Regulatory Changes · 67 signals · last 30 days -
Federal watchdog claims Medicare Part D sponsors paid $587.7M for over-the-counter drugs mislabeled as prescription-only
Medicare Part D sponsors paid pharmacies $587.7 million for some over-the-counter drugs with obsolete prescription-only labels, despite CMS oversight. Medicare Part D does not cover OTC drugs. According to an Aug. 31 HHS Office of Inspector General report, Part D sponsors made “ineligible” payments for five drugs — more than one year after the brand-name […] The post Federal watchdog claims Medicare Part D sponsors paid $587.7M for over-the-counter drugs mislabeled as prescription-only appear...
Policy / Regulatory Changes · 67 signals · last 30 days -
Medicare spent hundreds of millions of dollars on ineligible drugs, audit finds
Shoddy CMS oversight is to blame, and the agency needs to do better, the HHS Office of the Inspector General said. The CMS concurred.
Policy / Regulatory Changes · 67 signals · last 30 days -
Hospital groups rail against CMS' proposed 340B changes, site-neutral payments
Public comments for the latest OPPS proposed rule saw several major hospital groups all but threatening a court showdown over CMS' planned policy changes.
Policy / Regulatory Changes · 67 signals · last 30 days -
Agency Information Collection Activities: Proposed Collection; Comment Request
The Centers for Medicare & Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action. Int...
Policy / Regulatory Changes · 67 signals · last 30 days -
PUBLIC COMMENT — Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems, etc, CMS-1850-P, RIN 0938-AV83
The post PUBLIC COMMENT — Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems, etc, CMS-1850-P, RIN 0938-AV83 appeared first on Paragon Health Institute .
Policy / Regulatory Changes · 67 signals · last 30 days -
DOJ steps up crackdown on Medicare Advantage upcoding
The Justice Department’s scrutiny of Medicare Advantage risk adjustment is intensifying, with two recent settlements totaling nearly $1.1 billion highlighting federal concerns about diagnosis coding practices that can increase payments to health plans. The latest came Aug. 27, when The Villages (Fla.) Health System agreed to pay $541.5 million to resolve allegations that it violated […] The post DOJ steps up crackdown on Medicare Advantage upcoding appeared first on Becker's Payer Issues | Pa...
Policy / Regulatory Changes · 67 signals · last 30 days -
Trump admin blocks over $1.6B in potentially fraudulent Medicare lab payments: CMS
The CMS Fraud Defense Operations Center has also accounted for more than $371 million in Medicare suspended payments involving 267 providers and suppliers since Jan. 1, the agency said.
Policy / Regulatory Changes · 67 signals · last 30 days -
CMS Prevents $1.6 Billion in Fraudulent Medicare Laboratory Payments
CMS Prevents $1.6 Billion in Fraudulent Medicare Laboratory Payments 157 fraudulent lab providers revoked from Medicare program Centers for Medicare & Medicaid Services (CMS) enforcement actions have stopped more than $1.6 billion in potentially improper Medicare laboratory payments since the start of the Trump Administration – further evidence that CMS’ efforts to crush fraud are working to protect taxpayer dollars and improve Medicare program integrity. This includes $732 million in savings...
Policy / Regulatory Changes · 67 signals · last 30 days -
CMS touts blocking $1.6B in potentially fraudulent Medicare payments
CMS said its enforcement efforts have resulted in blocking more than $1.6 billion in possibly improper Medicare lab payments throughout President Trump’s administration. An Aug. 28 CMS news release said these enforcement actions included savings of $732 million from 157 providers with revoked Medicare privileges, and a CMS investigation of 600 labs that resulted in 185 payment […] The post CMS touts blocking $1.6B in potentially fraudulent Medicare payments appeared first on Becker's Payer Is...
Policy / Regulatory Changes · 67 signals · last 30 days -
Massachusetts Medicare Advantage insurer hit with enrollment freeze again
CMS has again suspended enrollment for two Medicare Advantage prescription drug plans offered by Boston-based EternalHealth, the second time in less than two years that the insurer has faced sanctions. The agency said Aug. 27 the enrollment freeze on the two plans is based on its determination that EternalHealth’s conduct “poses a serious threat to […] The post Massachusetts Medicare Advantage insurer hit with enrollment freeze again appeared first on Becker's Payer Issues | Payer News .
Policy / Regulatory Changes · 67 signals · last 30 days -
Federal court denies Elevance’s bid for emergency 2026 star ratings recalculation
A federal judge has denied Elevance Health’s request for an emergency recalculation of its 2026 Medicare Advantage star ratings. On Aug. 27, U.S. District Judge Lisa Godbey Wood ruled that Elevance waited too long to file for the emergency recalculation and failed to show that an injunction would prevent alleged competitive harm. In the same […] The post Federal court denies Elevance’s bid for emergency 2026 star ratings recalculation appeared first on Becker's Payer Issues | Payer News .
ElevanceElevance Health · 11 signals · last 30 days -
The Villages Health reaches $541M False Claims Act settlement with DOJ
The Villages Health System has agreed to a $541.5 million settlement to resolve allegations that it submitted false diagnosis codes to secure higher payouts in Medicare Advantage.
Policy / Regulatory Changes · 67 signals · last 30 days -
STAT+: CMS plans launch event for ACCESS, the Medicare chronic care pilot
In this edition of STAT Health Tech: CMS plans a launch event for Medicare chronic care pilot, and what the Meta settlement means for health AI.
Policy / Regulatory Changes · 67 signals · last 30 days -
$10M from Florida’s Centene Medicaid settlement misappropriated by DeSantis administration: Report
A state grand jury determined that $10 million from a Centene Medicaid settlement was “misappropriated” under Florida Republican Gov. Ron DeSantis’ administration, according to a Jan. 28 sealed document obtained by CBS News Miami. Despite the findings, the document said the grand jury lacked evidence to bring criminal charges. The settlement stemmed from claims of […] The post $10M from Florida’s Centene Medicaid settlement misappropriated by DeSantis administration: Report appeared first on...
Centene FloridaCentene · 11 signals · last 30 days -
Villages Health to pay $541.5M to settle Medicare Advantage fraud allegations
The Villages (Fla.) Health, a primary and specialty care provider group, has agreed to pay $541.5 million to resolve allegations that it violated the False Claims Act by submitting improper Medicare Advantage diagnosis codes, according to an Aug. 26 news release from the Justice Department. TVH, which sought Chapter 11 bankruptcy protection in July 2025 […] The post Villages Health to pay $541.5M to settle Medicare Advantage fraud allegations appeared first on Becker's Payer Issues | Payer Ne...
Policy / Regulatory Changes · 67 signals · last 30 days -
CMS releases fact sheet, FAQs on 340B claims data repository
The Centers for Medicare & Medicaid Services has released a fact sheet and FAQs on the 340B Part D claims data repository that will go live Oct. 1. Data submissions would currently be voluntary for 340B hospitals. However, the agency recently proposed to make data submissions mandatory starting in 2027. The fact sheet and FAQ provide an overview of the repository along with other key details.
Policy / Regulatory Changes · 67 signals · last 30 days -
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare
The Central Florida provider manufactured fake diagnosis codes for its Medicare Advantage patients from 2020 to 2024, the DOJ said. Humana bought The Villages Health last year.
Humana FloridaHumana · 13 signals · last 30 days -
Agency Information Collection Activities: Proposed Collection; Comment Request
The Centers for Medicare & Medicaid Services (CMS) is announcing an opportunity for the public to comment on CMS' intention to collect information from the public. Under the Paperwork Reduction Act of 1995 (PRA), federal agencies are required to publish notice in the Federal Register concerning each proposed collection of information (including each proposed extension or reinstatement of an existing collection of information) and to allow 60 days for public comment on the proposed action. Int...
Policy / Regulatory Changes · 67 signals · last 30 days -
Monogram Health to pay $2.4M to settle Medicare Advantage upcoding allegations
The Justice Department told Healthcare Dive that Monogram, a home health company, overcharged Medicare through contracts with Cigna and Humana by inflating diagnostic codes.
HumanaCignaHumana + Cigna · 22 signals · last 30 days -
Elevance Health to pay $15M to settle nurse overtime lawsuits
A federal judge has given final approval to a $14.75 million settlement between Elevance Health and a group of nurses who alleged the insurer misclassified them as exempt from overtime pay. U.S. District Judge David Novak signed off on the deal Aug. 20 in the Eastern District of Virginia, closing out five related lawsuits that […] The post Elevance Health to pay $15M to settle nurse overtime lawsuits appeared first on Becker's Payer Issues | Payer News .
Elevance VirginiaElevance Health · 11 signals · last 30 days -
Medicare Advantage provider agrees to $2.4M false claims settlement
Tennessee-based in-home care provider Monogram Health has agreed to pay $2.4 million to settle allegations that it caused the submission of false diagnosis codes to boost Medicare Advantage payments. From Jan. 1, 2021, through Dec. 31, 2023, Monogram allegedly knowingly submitted diagnosis codes that were not clinically accurate, not supported by patients’ medical records, or […] The post Medicare Advantage provider agrees to $2.4M false claims settlement appeared first on Becker's Payer Issu...
Policy / Regulatory Changes · 67 signals · last 30 days