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Tuesday, September 29 · 3 stories
- Legal
Baker Donelson Flags 2026 Medicare Fraud Enforcement Surge for Providers
In a client alert, Baker Donelson reports that CMS has imposed three nationwide Medicare enrollment moratoria in 2026 freezing new enrollment for home health agencies, hospices, and certain durable medical equipment suppliers. The firm notes these moratoria are running alongside a multiagency fraud task force, congressional investigations, and state oversight inquiries, with an August 2026 OIG white paper on durable medical equipment fraud signaling likely future enforcement tools. Providers and suppliers in these sectors, including those with dual Medicare-Medicaid enrollment, face heightened scrutiny now. The alert advises affected entities to prepare for expanded compliance reviews and potential parallel state Medicaid enforcement actions.
Monday, September 28 · 3 stories
- Legal
DOJ Revises Justice Manual on FCA Guidance Use, Qui Tam Dismissals
In a client alert, Bass, Berry & Sims reports that the Department of Justice has revised its Justice Manual to limit reliance on sub-regulatory guidance to establish legal duties in False Claims Act cases and to expand DOJ's use of dismissal authority over qui tam suits. The firm notes that guidance documents such as CMS manuals and Local Coverage Determinations remain usable as evidence of scienter, notice, industry standards, and medical necessity, even though they cannot themselves create the underlying legal obligation. Healthcare providers and Medicaid managed care organizations facing FCA exposure are most affected, since many billing and coverage disputes turn on sub-regulatory guidance. The firm does not specify an effective date for the revisions in the excerpt provided.
- Legal · GA
OIG Reviews Georgia Medicaid Fraud Control Unit's 2024 Operations
HHS OIG conducted its periodic onsite inspection of Georgia's Medicaid Fraud Control Unit, evaluating the unit's caseload, staffing, training, and compliance with federal performance standards for 2024. Medicaid Fraud Control Units investigate and prosecute provider fraud and patient abuse or neglect in Medicaid-funded facilities, and OIG's inspections assess whether states are meeting federal operational and reporting requirements. The report covers findings and any recommendations for Georgia's unit as of the 2024 review period. State Medicaid agencies and program integrity stakeholders use these reports to benchmark fraud unit performance and identify operational gaps.
- Legal
Brief Details Medicaid Fraud Control Units' Caseload and Outcomes
A policy brief explains how Medicaid Fraud Control Units (MFCUs) function within state program integrity efforts, drawing on caseload and case outcome data to describe their operations and current challenges. MFCUs investigate and prosecute provider fraud and patient abuse or neglect in Medicaid-funded facilities, working alongside state Medicaid agencies and federal oversight bodies. The brief does not describe a new rule or event but compiles background and data on unit performance and the issues they currently face. State Medicaid agencies, providers, and compliance officials rely on understanding MFCU activity to gauge fraud enforcement risk and program integrity priorities.
Friday, September 25 · 6 stories
- Legal
Labcorp Settles Multistate Data Breach Investigation for $2.28 Million
Labcorp agreed to pay $2.28 million to 44 state attorneys general to resolve an investigation into a 2019 data breach at its former debt-collection vendor, American Medical Collection Agency (AMCA). The breach at AMCA's parent company, Retrieval-Masters Creditors Bureau, exposed personal information of more than 27.5 million people nationwide. The settlement resolves state enforcement actions stemming from the vendor's inadequate data security practices. For Medicaid managed care organizations and providers using third-party vendors for billing and collections, this enforcement action underscores state regulators' willingness to hold covered entities accountable for vendor data security failures affecting patient information, including Medicaid beneficiaries.
- Legal · TN
Planned Parenthood Sues Tennessee AG Over Investigation Demanding Patient Records, Donor Details
Planned Parenthood of Tennessee and North Mississippi filed a legal challenge in Davidson County Chancery Court on Wednesday to block Attorney General Jonathan Skrmetti's investigative demand for donor information, provider credentials, and medical records of patients who received abortion referrals or gender-affirming care. The Sept. 3 demand letter targets the organization's post-abortion-ban services — providing information and out-of-state abortion referrals — and seeks records of patients treated for gender dysphoria, including named individuals and all minors who received gender-affirming care after July 1, 2023, when Tennessee's ban on such care for minors took effect. Planned Parenthood argues the demands violate free speech protections and constitute political intimidation; the AG's office says it has authority to request information when state law violations may have occurred. Abortion Care Tennessee disclosed this week it faces a similar investigation targeting medication abortion referral services.
- Legal
Warren, Wyden Introduce Bill to Ban Corporate Practice of Medicine Nationwide
In its September 25 publication, Foley & Lardner reports that Senators Elizabeth Warren, Ron Wyden, and Jeff Merkley, along with three House members, introduced the Stop Corporate Takeovers of Physicians Act on September 16, 2026. The legislation would impose federal restrictions on corporate practice of medicine (CPOM), targeting private equity ownership structures and management services organization (MSO) arrangements commonly used in physician practice acquisitions. If enacted, the bill would affect how private equity firms and corporate entities structure their investments in physician practices, potentially requiring restructuring of existing MSO-based transactions that rely on management agreements to circumvent state CPOM restrictions. The legislation matters for Medicaid managed care organizations and providers because many MCO networks include physician groups owned through MSO structures, and federal CPOM restrictions could disrupt network composition, provider contracting models, and care delivery arrangements.
- Legal
DOJ and State MFCU Enforcement Rises in Applied Behavior Analysis Billing
Epstein Becker & Green reports that Department of Justice and state Medicaid Fraud Control Unit enforcement activity targeting applied behavior analysis (ABA) providers has increased. The firm advises ABA providers to strengthen compliance programs by monitoring state Medicaid billing rules, scope-of-practice requirements, CMS guidance, and recent OIG audit findings. No specific enforcement actions or effective dates are identified. The guidance addresses compliance risk management for ABA providers billing Medicaid, particularly for behavioral health services.
- Legal · TN
OIG Finds Tennessee Improperly Claimed Millions in Federal Medicaid Reimbursement for Targeted Case Management
The HHS Office of Inspector General determined that Tennessee claimed federal Medicaid reimbursement for targeted case management services that failed to meet federal and state requirements. The audit identified millions of dollars in improper payments during the review period. Tennessee must repay the improper federal share and strengthen its oversight of targeted case management claims to ensure compliance with Medicaid program requirements. The finding underscores OIG's ongoing scrutiny of state compliance with service-specific billing standards and federal claiming accuracy.
- Legal · IA
Iowa Medicaid Fraud Elimination Task Force Defers Staffing Recommendations
Iowa Attorney General Brenna Bird stated Thursday that the state Medicaid Fraud Elimination Task Force, established by Governor Kim Reynolds on July 1, will address staffing and funding recommendations for the Medicaid Fraud Control Unit at future meetings rather than immediately. The task force is charged with submitting a final report at a date not specified in the source article. Critics have called for increased resources for fraud control efforts. The development affects Iowa's Medicaid program integrity operations and state enforcement capacity.
Thursday, September 24 · 2 stories
- Legal · MO
Missouri Medicaid Enrollee Sues Over Trump Administration Work Requirement Exemption Rule
A Missouri Medicaid enrollee has filed a lawsuit challenging a Trump administration rule governing work requirement exemptions, alleging procedural failures resulted in coverage loss. The enrollee, Emily Byrd of Kansas City, lost Medicaid coverage twice due to what the complaint describes as duplicate letters, late notices, and inconsistent information from the Missouri Department of Social Services despite submitting requested documentation. The lawsuit targets federal rules on exemption processes tied to Medicaid work requirements. The case adds to ongoing litigation over state work requirement programs and their administrative burden on beneficiaries.
- Legal
DOJ Revises False Claims Act Manual to Clarify Enforcement Standards
The Department of Justice updated its False Claims Act manual on September 18, 2026, reinstating and expanding a 2017 policy that subregulatory guidance cannot impose legal obligations beyond those established by statute or regulation. The revision aims to promote fairness and effective enforcement in fraud cases. The change affects how DOJ evaluates and pursues False Claims Act cases, including those involving Medicaid providers and health plans. The updated standards took effect immediately upon publication.
Wednesday, September 23 · 2 stories
- Legal · FL
Florida Sues Insulin Manufacturers and PBMs Over Alleged Price Inflation Scheme
Florida Attorney General James Uthmeier filed suit in Miami-Dade County Circuit Court against Eli Lilly, Novo Nordisk, Sanofi, and three pharmacy benefit managers, alleging they inflated insulin list prices and paid rebates that increased costs for consumers. The lawsuit accuses the companies of a coordinated pricing scheme involving diabetes medications. The action reflects growing state enforcement efforts targeting pharmaceutical pricing practices that affect state Medicaid pharmacy expenditures and beneficiary access to essential medications. The complaint follows similar insulin pricing litigation in other states.
- Legal · NY
OIG Finds New York Made Unallowable Capitation Payments for Incarcerated Enrollees
The HHS Office of Inspector General determined that New York made unallowable managed care capitation payments on behalf of incarcerated Medicaid enrollees. Federal law prohibits federal Medicaid funding for services provided to incarcerated individuals, with limited exceptions for inpatient hospital care. The audit findings indicate the state made capitation payments to managed care organizations for enrollees who were incarcerated during the coverage period. OIG recommendations typically require states to refund the federal share of identified overpayments and implement corrective actions to prevent future unallowable payments.
Tuesday, September 22 · 6 stories
- Legal · TX
Texas Hospitals Sue Independence Blue Cross Over Denied Claims Under BlueCard Program
Five HCA-affiliated hospitals in Texas have filed suit against Independence Blue Cross alleging the insurer continues to improperly deny claims through the BlueCard program despite a previous $2.8 billion settlement over BlueCard disputes. The hospitals claim the program subjects them to excessive administrative burdens and claim denials. The litigation follows broader industry concerns about cross-state claims processing under the BlueCard reciprocal network. This matters for Medicaid managed care plans operating Blue Cross Blue Shield-branded products, as BlueCard network arrangements and claims adjudication practices affect provider participation and reimbursement across state lines.
- Legal · CT
OIG Finds Connecticut DDS Failed to Monitor HCBS Waiver Compliance for Home Support Services
The HHS Office of Inspector General found that Connecticut's Department of Developmental Services did not ensure providers of individualized home support services fully complied with federal waiver requirements and state health and safety standards. The audit identified gaps in state oversight, including inadequate monitoring of service delivery, health and safety protocols, and provider compliance with waiver terms. OIG recommended that Connecticut strengthen oversight mechanisms to ensure providers meet federal Home and Community-Based Services waiver requirements. The findings highlight enforcement gaps that could affect beneficiary health and safety and federal waiver compliance.
- Legal
DOJ Revises Justice Manual to Strengthen False Claims Act Enforcement
On September 18, 2026, the Department of Justice announced revisions to the Justice Manual strengthening False Claims Act enforcement. The changes affect how DOJ pursues FCA cases, including potential modifications to dismissal policies and limitations on relying on sub-regulatory guidance as the basis for FCA liability. Healthcare providers, including those serving Medicaid beneficiaries, face increased enforcement scrutiny. The revisions took effect immediately upon announcement.
- Legal
FinCEN Flags $17.5B in Suspected Health Care Fraud Across Medicare and Medicaid
On September 9, 2026, the Financial Crimes Enforcement Network (FinCEN) issued a Financial Trend Analysis identifying approximately $17.5 billion in suspicious activity potentially linked to health care fraud. The analysis is based on more than 5,700 Bank Secrecy Act reports filed between March 2025 and February 2026, with roughly 89 percent originating from depository institutions. The suspected fraud schemes targeted Medicare, Medicaid, and private insurance programs. This alert signals heightened financial institution monitoring of health care transactions and potential increased enforcement scrutiny across all payers, including Medicaid.
- Legal · NC
Abbott Pays $384M to Settle Medicaid Fraud Claims Over 2022 Formula Contamination
Abbott Laboratories agreed to pay $384 million to resolve federal and state allegations that it caused Medicaid to pay for contaminated infant formula prior to the 2022 recall and shortage. North Carolina will receive over $216,000 as part of the multistate settlement. The settlement addresses claims that Abbott violated the False Claims Act by distributing adulterated formula that was reimbursed by Medicaid. The case stems from the February 2022 recall of formula manufactured at Abbott's Sturgis, Michigan facility after bacterial contamination led to infant illnesses and deaths.
- Legal
Medical Groups and Enrollees Sue Over Federal Medicaid Work Requirements
Medicaid enrollees from five states and medical organizations filed suit Friday challenging work requirements established under the One Big Beautiful Bill Act signed by President Trump in summer 2026. The lawsuit targets new federal mandates requiring low-income adults in Medicaid expansion populations to meet work, school, or community service requirements. The legal challenge directly affects expansion enrollees in participating states and could determine whether millions of beneficiaries face coverage loss for non-compliance. The outcome will shape state implementation timelines and whether states must enforce work requirements pending judicial review.
