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Monday, September 21 · 2 stories
- Legal
NYU Langone, UPMC Settle DOJ Gender-Affirming Care Cases for $9.45M
NYU Langone Health and University of Pittsburgh Medical Center reached settlements with the U.S. Department of Justice totaling $9.45 million ($8.5 million and $950,000 respectively) and agreed to discontinue pediatric gender-affirming care services. The settlements were announced September 18, 2026. The agreements affect pediatric behavioral health and specialty care delivery at two major academic medical centers, both of which likely serve Medicaid-enrolled children. The DOJ enforcement action signals heightened federal scrutiny of gender-affirming care practices for minors, with direct implications for health systems, managed care plans covering these services, and state Medicaid agencies determining covered benefits.
- Legal
Federal Judge Dismisses Challenge to Title X Grant Process Changes
A federal judge in Pennsylvania dismissed a lawsuit filed by the National Family Planning and Reproductive Health Association and the Family Health Council of Central Pennsylvania challenging HHS's revised Title X grant application process. The plaintiffs alleged the new alignment review requirements politicized funding decisions and violated statutory intent, but U.S. District Judge Jennifer P. Wilson ruled they did not demonstrate sufficient concrete harm to establish standing. The revised 2027 funding round shifts Title X priorities from contraception access to pregnancy promotion and family formation, though HHS removed language allowing outright rejection based on alignment review after the lawsuit was filed.
Friday, September 18 · 1 story
- Legal · VT
Vermont Provider Settles Medicaid Fraud Allegations for $390,000
Health Care & Rehabilitation Services of Southeastern Vermont will pay $390,000 to resolve allegations it mishandled Medicaid funds. The settlement also requires the provider to adopt new compliance policies. The case involved claims that the organization improperly managed federal Medicaid dollars. The settlement demonstrates continued state and federal enforcement activity targeting Medicaid billing and fund management practices at community-based providers.
Thursday, September 17 · 4 stories
- Legal
OIG Finds Humana and UnitedHealth MA Plans Generated $180M in Upcoding Overpayments
HHS OIG audits released September 17, 2026 found that HumanaChoice and UnitedHealthcare of Wisconsin overstated member health conditions in Medicare Advantage risk adjustment submissions, resulting in nearly $180 million in overpayments over a two-year period. The audits concluded both plans frequently exaggerated health needs to inflate capitation payments. OIG has referred the findings to CMS for recovery action. While these audits focus on Medicare Advantage, they signal heightened federal scrutiny of risk adjustment practices that could extend to Medicaid managed care plans using similar diagnosis-driven payment models.
- Legal
CMS Affiliation Rule Enables 10-Year Medicare Enrollment Bars for Physicians Without Direct Violations
Under current Medicare enrollment regulations, physicians can face up to 10-year exclusions from treating Medicare patients based solely on affiliation with another provider or supplier that has compliance issues, even when the physician has no personal history of fraud, improper billing, or disciplinary actions. The affiliation rule allows CMS to deny or revoke enrollment based on an individual's relationship with an entity that has been sanctioned or excluded. This administrative action does not require proof that the physician submitted improper claims or engaged in wrongdoing. The rule particularly affects hospice medical directors and other physicians in administrative or leadership roles where formal affiliations are documented.
- Legal · NC
OIG Finds North Carolina Medicaid Fraud Control Unit Compliant in 2025 Inspection
The HHS Office of Inspector General conducted an onsite inspection of North Carolina's Medicaid Fraud Control Unit in 2025 and found the unit in compliance with federal certification standards. The inspection reviewed the unit's investigative capacity, case management procedures, staffing levels, and coordination with state Medicaid agencies and law enforcement partners. MFCU certification is required for states to receive federal matching funds for fraud control activities. The findings confirm North Carolina maintains adequate resources and protocols to investigate and prosecute Medicaid provider fraud and beneficiary abuse.
- Legal · TX
Texas Family Sues Attorney General Paxton Over Denied Abortion Leading to Maternal Death
The family of Tierra Walker, a 37-year-old Texas woman who died from preeclampsia in 2024, filed a lawsuit Wednesday against Texas Attorney General Ken Paxton and doctors who denied her an abortion. Walker experienced seizures, blood clots, and hypertensive crisis at four months pregnant and requested abortion care multiple times before her death. The lawsuit challenges enforcement of Texas abortion restrictions that allegedly prevented medically necessary care. This case follows several wrongful death and civil rights lawsuits filed nationwide challenging state abortion laws and their impact on maternal health outcomes.
Wednesday, September 16 · 4 stories
- Legal · AR
Arkansas Pharmacies File First Lawsuit Against Express Scripts Under State PBM Payment Law
Twelve independent Arkansas pharmacies filed suit against Express Scripts, marking the first use of a 2025 state law authorizing pharmacies to sue pharmacy benefit managers for underpayments. The lawsuit tests new enforcement authority granted to pharmacies under Arkansas legislation targeting PBM reimbursement practices. The case could establish precedent for pharmacy challenges to PBM payment methodology in Arkansas and influence similar legislative efforts in other states. The outcome affects Medicaid managed care plans that contract with Express Scripts for pharmacy services and may impact PBM reimbursement practices across state Medicaid programs.
- Legal
DOL Warns Plans to Maintain Mental Health Parity Compliance Despite Non-Enforcement Posture
The Department of Labor, HHS, and Treasury have adopted a non-enforcement posture for the final Mental Health Parity and Addiction Equity Act regulations published in fall 2024, but are warning employers and health plans that compliance remains expected. The guidance signals that while the agencies are not actively enforcing the 2024 final rule, they continue to monitor mental health parity compliance more broadly. This creates compliance uncertainty for Medicaid managed care plans and other health plans that must determine which parity requirements remain enforceable and how to demonstrate compliance without clear enforcement standards.
- Legal
Home-Based Care Providers Face Heightened Medicaid Program Integrity Oversight Amid AI Adoption
Home health and home-based care providers are experiencing increased Medicare and Medicaid program integrity scrutiny while navigating AI technology implementation. Providers are advised to prioritize AI governance, compliance protocols, and vendor management to mitigate regulatory risk. Recommended actions include conducting internal data reviews and compliance audits. The guidance addresses operational risks for providers serving Medicaid beneficiaries under heightened federal and state oversight of billing, documentation, and technology use.
- Legal · NC
Federal Court Ends 14-Year North Carolina Mental Health Settlement Oversight
U.S. District Judge James C. Dever III terminated court oversight of North Carolina's Transitions to Community Living program Monday, ending a 2012 settlement with the U.S. Justice Department. The settlement required North Carolina to transition people with serious mental illness from institutional settings to community housing with wraparound services. While the state exceeded some targets — housing 3,998 people against a 3,000 goal — an independent reviewer found the state failed to meet 2025 benchmarks for supported housing slots from adult care homes, providing only 1,022 of a required 2,000 slots. Both parties agreed to end oversight early despite gaps, citing substantial compliance overall.
Tuesday, September 15 · 2 stories
- Legal
CMS Defers $1 Billion in Medicaid Payments and Expands Provider Exclusion Authority
CMS has deferred $1 billion in Medicaid payments as part of a federal crackdown on fraud, waste, and abuse in healthcare. The agency has also gained new authority to exclude providers from Medicaid participation. These actions represent a significant expansion of CMS enforcement powers affecting both providers and state Medicaid programs. The changes follow earlier federal commitments to intensify program integrity efforts across healthcare programs.
- Legal · MD
Maryland Sues Optum for $126 Million Over Allegedly Defective Medicaid Behavioral Health Claims System
Maryland filed suit against Optum and UnitedHealth Group alleging Optum collected over $126 million while operating a behavioral health Medicaid claims system the state contends was never fully functional during the five-year contract period. The lawsuit asserts fraud and breach of contract related to the system's performance failures. The timing of the suit is current as of September 2026, though the underlying contract issues span multiple years. This represents significant state-level enforcement against a major managed care and technology vendor, potentially signaling increased scrutiny of Medicaid administrative service contracts and vendor performance accountability.
Monday, September 14 · 1 story
- Legal · AL
OIG Inspects Alabama Medicaid Fraud Control Unit Operations in 2025
The HHS Office of Inspector General conducted an inspection of Alabama's Medicaid Fraud Control Unit in 2025. These periodic inspections assess MFCU compliance with federal certification standards, including case management, staffing, prosecution capabilities, and coordination with state Medicaid agencies. The inspection reviewed the unit's investigative procedures, conviction rates, and financial recoveries. Results inform OIG's ongoing oversight of state fraud control operations and federal funding decisions for MFCUs.
Friday, September 11 · 2 stories
- Legal
Second Circuit Eases Pleading Standards for Reverse False Claims Act Cases
The U.S. Court of Appeals for the Second Circuit ruled that False Claims Act relators can satisfy Federal Rule of Civil Procedure 9(b) pleading requirements without identifying every false claim in an alleged fraudulent scheme. The decision in United States ex rel. Gallian v. AmerisourceBergen also left unresolved whether Rule 9(b)'s heightened pleading standards apply at all to reverse False Claims Act claims, which involve defendants who improperly retain government overpayments rather than submitting false claims for payment. The ruling applies to cases filed in the Second Circuit (Connecticut, New York, Vermont) and may influence how FCA cases proceed in other jurisdictions.
- Legal · NY
Brooklyn Home Health Owner Sentenced to 76 Months for $64M Medicaid Fraud Scheme
A Brooklyn federal court sentenced Zakia Khan, owner of adult day and home health companies, to 76 months in prison for orchestrating a multiyear Medicaid fraud and illegal kickback scheme. Khan pleaded guilty in 2025 to conspiring to defraud Medicaid and pay healthcare kickbacks, fraudulently billing the program approximately $64 million. The sentence was handed down Wednesday, September 9, 2026. This case underscores heightened federal enforcement against Medicaid fraud in home health and adult day services, particularly schemes involving fiscal intermediaries and kickback arrangements.
Thursday, September 10 · 1 story
- Legal
CMS Releases Guidance on ABA Therapy Compliance Amid Rising Fraud Concerns
CMS has issued new guidance addressing compliance and payment-integrity risks in applied behavior analysis (ABA) therapy for autism, one of Medicaid's fastest-growing service categories. The guidance responds to increasing expenditures, varying clinical practices, and reported fraud schemes in ABA services. Rapid program growth, extensive use of paraprofessional staff, and complex documentation and supervision requirements have created heightened compliance risks. The guidance affects state Medicaid agencies overseeing ABA programs, managed care organizations with behavioral health responsibilities, and ABA providers navigating fraud and abuse prevention requirements.
Wednesday, September 9 · 1 story
- Legal · LA
Louisiana Appeals Court Reviews Challenge to Telehealth Abortion Access
A federal appeals court is considering Louisiana's lawsuit seeking to terminate telehealth abortion access. The case challenges the legality of remote provision of medication abortion services. The timing and scope of any ruling remain uncertain. The outcome could affect Medicaid coverage of telehealth reproductive health services in Louisiana and potentially establish precedent affecting other states' telemedicine policies for abortion and related services.
Tuesday, September 8 · 3 stories
- Legal · CA
California Failed to Report and Return $6.8 Million in Medicaid Fraud Unit Overpayments
The HHS Office of Inspector General found that California did not report and return $6.8 million in Medicaid overpayments identified through its Medicaid Fraud Control Unit cases from 2019 to 2022. California reported only $27.4 million of $34.2 million in identified overpayments to CMS and returned just $24 million. The state failed to track overpayments adequately and did not follow federal requirements for reporting and returning recovered funds within 60 days. OIG recommends California strengthen controls, return the unreported amounts, and provide technical assistance to counties on federal overpayment requirements.
- Legal · SC
OIG Finds South Carolina Failed to Monitor MCO Mental Health Parity Compliance on Prior Authorization
An HHS Office of Inspector General audit found that South Carolina's Medicaid agency did not ensure that three managed care organizations complied with federal mental health and substance use disorder parity requirements for prior authorization processes during the audit period. The state lacked adequate oversight mechanisms to verify that MCOs applied comparable prior authorization criteria and processes for behavioral health services as for medical/surgical benefits. OIG recommended that South Carolina strengthen monitoring protocols and ensure MCOs document parity compliance. The findings highlight enforcement gaps in the Mental Health Parity and Addiction Equity Act as applied to Medicaid managed care.