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Monday, June 22 · 1 story
- Legal
DOJ Intensifies Medicaid Fraud Enforcement Under Trump Administration
The Trump Administration has significantly increased enforcement focus on waste, fraud, and abuse in Medicaid over the past six months, with the Department of Justice prioritizing False Claims Act cases against Medicaid providers and managed care organizations. This heightened scrutiny follows longstanding federal efforts to recover improper Medicaid payments but marks a notable acceleration in enforcement activity. The increased DOJ attention raises compliance and financial risk for Medicaid managed care plans, particularly around billing accuracy, utilization management, and encounter data reporting. Plans should expect more qui tam investigations and potential enforcement actions.
Friday, June 19 · 1 story
- Legal
California Court Issues Evidentiary Ruling in EKRA Criminal Prosecution
A federal district court in California ruled on evidentiary and testimonial issues in United States v. Simons, a criminal prosecution under the Eliminating Kickbacks in Recovery Act (EKRA). The May 1, 2026 decision provides early judicial guidance on how courts will handle evidence in EKRA cases as enforcement expands beyond substance use disorder treatment facilities. EKRA prohibits kickbacks for patient referrals to recovery homes and clinical treatment facilities. The ruling affects Medicaid managed care organizations that contract with behavioral health providers, substance use disorder treatment networks, and recovery services, as EKRA enforcement increasingly targets referral arrangements in these settings.
Thursday, June 18 · 1 story
- Legal · IL
PCMA Files Lawsuit Challenging Illinois PBM Reform Law
The Pharmaceutical Care Management Association (PCMA) has filed a lawsuit seeking to exempt pharmacy benefit managers from an Illinois law reforming the PBM industry. This marks the second major legal challenge PCMA has launched against state PBM reform legislation since Monday. The lawsuit targets Illinois's attempt to regulate PBM practices, though specific provisions challenged are not detailed in the article. The legal action follows a pattern of PBM industry opposition to state-level regulatory efforts through preemption and other legal arguments.
Wednesday, June 17 · 3 stories
- Legal
Legal Aid Groups Convene on Medicaid Cuts and Automated Eligibility Denials
Legal advocates gathered at the ABA/NLADA Equal Justice Conference in Charlotte to address threats to Medicaid from proposed federal budget cuts and automated eligibility systems. The National Health Law Program highlighted concerns about the One Big Beautiful Bill Act, which proposes significant Medicaid spending reductions, and automated systems that are denying coverage to eligible beneficiaries. The conference focused on legal strategies to protect Medicaid access and eligibility processes. No specific implementation dates or regulatory actions were announced.
- Legal
Olmstead Decision Marks 27 Years as Community Integration Faces Medicaid Budget Threats
The 27th anniversary of Olmstead v. L.C. arrives as the landmark Supreme Court decision establishing the right to community-based services faces new challenges from proposed Medicaid cuts. The 1999 ruling required states to provide services in the most integrated setting appropriate to individuals' needs, fundamentally reshaping long-term services and supports delivery through Medicaid managed care. Current budget proposals threaten funding for home and community-based services that emerged from Olmstead's community integration mandate, potentially reversing decades of progress in moving individuals out of institutional settings.
- Legal · NY
DOJ Sues New York DOH and PPL Over CDPAP Fiscal Intermediary Fraud Allegations
The U.S. Department of Justice filed a lawsuit Tuesday against the New York Department of Health and Public Partnerships LLC (PPL), alleging fraud in the state's transition of the Consumer Directed Personal Assistance Program (CDPAP) to a single fiscal intermediary. DOJ claims the arrangement was designed to extract millions from New York's Medicaid program through improper payments. The lawsuit targets both the state agency that selected PPL and the fiscal intermediary itself. CDPAP allows Medicaid beneficiaries to direct their own long-term care services, with fiscal intermediaries handling payroll and administrative functions.
Tuesday, June 16 · 2 stories
- Legal · TN
Express Scripts, PCMA Sue Tennessee Over Law Requiring PBM-Pharmacy Separation
Express Scripts and the Pharmaceutical Care Management Association filed lawsuits challenging Tennessee's FAIR Rx Act, which mandates the separation of pharmacy benefit managers from retail pharmacies. The law, passed earlier this year over strong PBM industry opposition, aims to prevent vertical integration practices that critics argue drive up drug costs and limit pharmacy access. The litigation follows similar legal action by CVS Caremark. The outcome will affect how Medicaid managed care plans structure pharmacy benefits and contract with PBMs in Tennessee and potentially influence similar legislative efforts in other states.
- Legal
Federal Judge Vacates Most of 2025 ACA Enrollment and Eligibility Rule
A federal judge on Friday vacated the majority of CMS's 2025 ACA enrollment and eligibility rule, delivering a win for insurance advocates who challenged the regulation. The vacated provisions included controversial changes to enrollment processes and eligibility verification requirements. However, many of the rule's provisions have been incorporated into the GOP's reconciliation bill currently moving through Congress, limiting the practical impact of the court decision. The ruling does not affect state-based marketplaces or Medicaid operations directly.
Friday, June 12 · 3 stories
- Legal · HI
HHS OIG Warns Hawaii of Potential Medicaid Fraud Sanctions Over Eligibility Concerns
On May 13, 2025, HHS Inspector General Christi Grimm sent a letter to Hawaii warning of potential administrative sanctions over alleged Medicaid eligibility fraud. The letter was announced by Vice President Vance at a White House Task Force press conference alongside news of a $1.3 billion federal Medicaid payment deferral to California. The OIG letter to Hawaii signals aggressive federal enforcement activity targeting state Medicaid programs for eligibility determinations. The timing and public announcement through the White House suggest coordinated federal pressure on states over Medicaid program integrity issues.
- Legal · AK
Planned Parenthood Sues Alaska Over Medication Abortion Telehealth Ban
Planned Parenthood Great Northwest filed a lawsuit Thursday in Alaska state court challenging the state's requirement that medication abortion be provided only in person, arguing it violates Alaska's constitutional right to abortion. The lawsuit seeks a preliminary injunction against the telehealth ban. Alaska is among states restricting medication abortion access through telehealth despite broader telemedicine expansion. The case affects how Medicaid managed care plans handle abortion coverage and telehealth protocols in Alaska, particularly for reproductive health services where telehealth has become standard in other states.
- Legal · OH
Ohio Medicaid Suspends Payments to 49 Home Health Providers Over Billing Patterns
The Ohio Department of Medicaid suspended payments to 49 home health providers based on suspicious billing patterns, marking an early state-level response to CMS guidance on heightened program integrity enforcement. The suspensions target at-home care providers and reflect a broader shift in Medicaid oversight from traditional post-payment review to proactive payment holds. The timing and scope of the action align with recent CMS directives emphasizing aggressive fraud prevention in home and community-based services. This signals that states are accelerating enforcement activity in the LTSS and home health sectors, where billing irregularities have drawn increased federal attention.
Wednesday, June 10 · 1 story
- Legal
USCIS Restricts Green Card Adjustments to Extraordinary Relief Cases
On May 21, 2026, USCIS issued a policy memo limiting green card issuance through adjustment of status to applicants demonstrating extraordinary circumstances. The memo recharacterizes adjustment of status as a discretionary measure rather than an expected benefit. This policy change affects the immigration pathways available to foreign-born healthcare workers, including those employed by Medicaid managed care organizations and provider networks. The restriction takes effect immediately and may impact MCO workforce planning and recruitment strategies for clinical and administrative staff.
Monday, June 8 · 2 stories
- Legal
California Doctor Convicted in $45 Million Medicare Botox Fraud Scheme
A federal jury in the Central District of California convicted Dr. Violetta Mailyan for orchestrating a $45 million Medicare fraud scheme involving fraudulent Botox injection claims. The conviction reflects DOJ's increasing use of data analytics to identify and prosecute billing anomalies and fraud patterns in federal health programs. The case demonstrates heightened federal enforcement targeting suspicious billing practices, particularly for high-cost procedure codes and injectable medications. Medicaid managed care organizations face similar fraud detection scrutiny and should strengthen their claims review protocols and provider oversight mechanisms.
- Legal
DOJ Orders Fast-Track Review of Sealed Medicaid False Claims Act Cases
The Department of Justice announced May 27, 2026, that civil attorneys must prioritize and expedite sealed qui tam cases alleging fraud against Medicaid and other federally funded, state-administered benefit programs. Assistant Attorney General Brett Shumate directed DOJ Civil Division and U.S. Attorney's Office lawyers to fast-track these investigations. The directive applies immediately to pending sealed cases. This signals heightened federal enforcement scrutiny of Medicaid fraud allegations and may accelerate the timeline from complaint filing to government intervention decisions or unsealing.
Friday, June 5 · 1 story
- Legal · OH
Ohio Suspends 49 Home Health Providers for Billing Irregularities
The Ohio Department of Medicaid suspended payments to 49 home health providers on Thursday following identification of suspicious billing patterns. The action aligns with broader federal enforcement efforts targeting Medicaid-funded home-based care. The suspensions appear connected to a gubernatorial executive order, though implementation details were not specified in the announcement. Managed care organizations contracting with affected providers should review care continuity protocols and confirm any required network substitutions.
Thursday, June 4 · 2 stories
- Legal · HI
HHS OIG Defunds Hawaii Medicaid Fraud Control Unit After Four Years Without Indictments
The HHS Office of Inspector General will not recertify Hawaii's Medicaid Fraud Control Unit, cutting off $3 million in federal funding after the unit failed to produce any indictments or convictions over four years. Inspector General March Bell notified Hawaii Attorney General Anne Lopez of the decision in a letter. The decertification means Hawaii loses federal matching funds for its MFCU operations. This is the first known instance of OIG defunding a state MFCU for performance failure.
- Legal
Federal Trial Links Fake Nursing Diploma Mill to Patient Death in Florida Fraud Case
Federal prosecutors opened trial in Fort Lauderdale on June 1 for the final contested case from Operation Nightingale, a fraud scheme that sold approximately 15,000 fake nursing credentials over three years. For the first time, prosecutors are connecting the diploma mill scheme to a patient death. The trial represents the conclusion of a federal enforcement action that exposed thousands of individuals with fraudulent nursing degrees working in healthcare facilities nationwide.
Wednesday, June 3 · 2 stories
- Legal · TX
Texas Appeals Court Denies Novartis Petition to Halt Medicaid Fraud Qui Tam Case
The Fifteenth Court of Appeals in Texas denied Novartis Pharmaceuticals' request for mandamus relief to halt a Medicaid qui tam action brought under the Texas Medicaid Fraud Prevention Act (TMFPA). While the court acknowledged "weighty" constitutional questions raised by Novartis regarding the TMFPA's qui tam provisions, it ruled that these challenges must be addressed through ordinary appellate review rather than through extraordinary mandamus relief. The decision allows the underlying fraud case to proceed. The ruling affirms that constitutional challenges to state Medicaid fraud statutes, even when substantial, do not automatically warrant immediate appellate intervention before trial court resolution.
- Legal
DOJ Announces Faster False Claims Act Reviews and Expanded Federal Program Fraud Enforcement
The Department of Justice issued a May 27 memorandum accelerating False Claims Act enforcement timelines and expanding focus on federal benefits programs. The new policy directs faster qui tam case reviews, earlier enforcement decisions, and more aggressive fraud identification in federal health programs including Medicaid. The changes take effect immediately and apply to all pending and future FCA matters. This shift means managed care organizations should expect shorter review periods before DOJ intervenes or declines qui tam cases, with heightened scrutiny of billing practices and program integrity across all federal healthcare programs.
Tuesday, June 2 · 3 stories
- Legal
DOJ Launches West Coast Strike Force Targeting Health Care Fraud in Three Districts
The Department of Justice announced the creation of the West Coast Health Care Fraud Strike Force on April 30, 2026, combining fraud enforcement operations across the District of Arizona, District of Nevada, and Northern District of California with a focus on Silicon Valley. The strike force will coordinate investigations and prosecutions across these three federal districts. This expanded enforcement capacity increases audit and investigation risk for Medicaid managed care organizations operating in the western states, particularly those with behavioral health, telehealth, or technology-enabled care delivery models that have drawn recent DOJ scrutiny.