The Vice President and HHS Secretary have referred dozens of hospitals, pharmacy benefit managers, and pharmacies to the Department of Justice and HHS Office of Inspector General for investigation of potentially fraudulent billing related to pediatric gender-affirming care. The referrals follow a new HHS report identifying organizations for scrutiny. The investigations will focus on billing practices for these services. This represents a significant enforcement action affecting hospitals and pharmacies providing or processing claims for pediatric gender-affirming treatment.
Why it mattersMedicaid managed care plans and state agencies overseeing these services face potential claims recoupment, contract compliance reviews, and heightened scrutiny of prior authorization and claims processing for gender-affirming care.
Behavioral Health · Pharmacy · Managed Care
The Department of Justice announced its annual Health Care Fraud Takedown on June 23, 2026, with Medicaid and state health care programs representing a central enforcement focus. The takedown reflects DOJ's heightened scrutiny of fraud and abuse affecting state programs, not just Medicare. Medicaid providers, managed care organizations, and state agencies face increased risk of federal enforcement action. This enforcement prioritization signals that DOJ views Medicaid fraud as a critical target area requiring robust compliance programs and internal controls.
Why it mattersThe enforcement shift means Medicaid MCOs and providers must strengthen fraud detection, reporting, and compliance infrastructure to mitigate federal investigation and False Claims Act exposure.
Managed Care · Finance
The Fifth Circuit Court of Appeals ruled Tuesday that insurers cannot include ghost rates or exclude bonus payments when calculating the qualifying payment amount (QPA) under the No Surprises Act. The QPA serves as the default benchmark in independent dispute resolution for out-of-network emergency and air ambulance claims. The decision takes effect immediately and will increase reimbursement amounts paid to out-of-network providers. For Medicaid managed care plans that also operate commercial business, this ruling affects how their commercial lines calculate out-of-network payments, though the No Surprises Act does not apply directly to Medicaid.
Why it mattersThis ruling will increase costs for commercial insurers, including Medicaid MCOs with dual lines of business, and may influence future out-of-network payment disputes in states with similar balance billing protections.
Managed Care
PatientRightsAdvocate.org has filed a lawsuit challenging the American Medical Association's copyright of Current Procedural Terminology (CPT) codes. The suit argues that because federal law requires use of CPT codes for billing Medicare and Medicaid, the codes should be publicly available rather than copyrighted. The lawsuit does not specify when it was filed or what relief is sought. The outcome could affect provider billing practices and access to coding information across Medicare and Medicaid programs.
Why it mattersA successful challenge could eliminate licensing fees for CPT codes that Medicaid managed care plans and providers currently pay to the AMA for billing compliance.
Managed Care · Finance
Approximately 6% of hospice patients are discharged from hospice care when their condition improves or stabilizes, losing eligibility under Medicare's requirement that patients have a life expectancy of six months or less. These disenrollments affect patients and families who must navigate care transitions after receiving terminal diagnoses. The practice reflects Medicare hospice benefit certification requirements that physicians must recertify terminal prognosis at specific intervals. This matters for Medicaid beneficiaries eligible for hospice through their state programs, as Medicaid hospice benefits typically mirror Medicare eligibility standards, and disenrollment can disrupt continuity of care for dually eligible individuals.
Why it mattersMedicaid hospice programs follow Medicare eligibility standards, making disenrollment practices directly relevant to care coordination for dually eligible beneficiaries and state program administration.
LTSS · Managed Care