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Friday, August 28 · 4 stories
- Legal
McDermott Compliance Clinic Examines Chronic Care Management Billing Risks
McDermott Will & Emery published a compliance analysis examining chronic care management (CCM) services billing, coding, audit exposure, and enforcement risk across Medicare and Medicaid programs. The analysis addresses how providers can structure CCM programs to minimize compliance risk during government audits and investigations. It covers documentation requirements, time-tracking protocols, and common billing errors that trigger OIG scrutiny. The guidance is relevant for Medicaid managed care plans and providers offering CCM services under capitated or fee-for-service arrangements.
- Legal
CMS and OIG Prioritize Wound Care Fraud Enforcement in 2026
The Centers for Medicare and Medicaid Services and the HHS Office of Inspector General have made wound care fraud enforcement a priority in 2026. Healthcare providers offering wound care services face increased audit and investigation risk. Non-compliance can result in substantial penalties, including potential Medicare or Medicaid exclusion. Providers should review their wound care billing practices, documentation standards, and compliance programs to mitigate enforcement exposure.
- Legal
23 States Sue Trump Administration Over Family Planning Grant Requirements
A coalition of 23 states filed suit in Maryland federal court Thursday challenging new conditions on family planning grants that would allegedly require states and providers to align with administration political priorities or lose federal funding. The lawsuit contests restrictions that could affect Title X family planning program funding, which supports reproductive health services including contraception and preventive care for Medicaid beneficiaries. The litigation seeks to block implementation of the new grant requirements. The outcome will determine whether states retain existing federal family planning funding or must choose between compliance with new federal conditions and maintaining current service delivery models.
- Legal · FL
Florida Judge Allows Pediatric Associates Challenge to Medicaid ABA Rates
An administrative law judge ruled that Pediatric Associates has standing to challenge Florida's Medicaid reimbursement rates for applied behavioral analysis (ABA) services for children with autism. Division of Administrative Hearings Judge W. David Watkins denied the state's motion to dismiss the case on Wednesday. The provider alleges the DeSantis administration miscalculated rates that fail to cover ABA service costs. The ruling allows the rate challenge to proceed to a full hearing on the merits.
Thursday, August 27 · 3 stories
- Legal
Humana-Owned Villages Health Settles Medicare Advantage Upcoding Case for $542M
The Villages Health, acquired by Humana in 2025, agreed to pay $542 million to settle allegations it submitted fabricated diagnosis codes to inflate Medicare Advantage risk-adjusted payments from 2020 to 2024. The Department of Justice alleged the Central Florida provider systematically manufactured diagnoses to increase capitation rates. The settlement represents one of the largest Medicare Advantage fraud recoveries to date and follows heightened federal scrutiny of MA risk adjustment practices.
- Legal · FL
Florida Grand Jury Finds $10M from Centene Medicaid Settlement Misappropriated
A Florida state grand jury determined that $10 million from a Centene Medicaid settlement was misappropriated under the DeSantis administration, according to a sealed January 28 document obtained by CBS News Miami. The grand jury found insufficient evidence to bring criminal charges. The settlement originated from claims against Centene related to its Florida Medicaid managed care operations. The finding raises questions about state oversight of Medicaid settlement funds and their designated use.
- Legal
ABA Therapy Faces Growing Federal and State Fraud Enforcement Scrutiny
Applied behavior analysis therapy for autism has become a major Medicaid enforcement target as the service category expands rapidly. Federal and state regulators are increasing scrutiny of ABA providers for potential fraud, waste, and abuse violations. ABA providers face heightened compliance risk due to the service's growth trajectory, billing complexity, and evolving coverage policies. The enforcement environment creates significant operational and legal exposure for providers, managed care organizations overseeing ABA networks, and state Medicaid agencies administering these benefits.
Wednesday, August 26 · 3 stories
- Legal
Monogram Health Settles Medicare Advantage Upcoding Claims for $2.4 Million
Monogram Health, a home health company, will pay $2.4 million to settle Justice Department allegations that it overcharged Medicare Advantage plans through inflated diagnostic codes in contracts with Cigna and Humana. The settlement resolves claims that Monogram systematically upcoded patient diagnoses to increase risk-adjusted payments to MA plans. The enforcement action reflects continued federal scrutiny of diagnosis coding practices in Medicare Advantage, particularly involving delegated provider arrangements that impact plan payments.
- Legal
129 Groups Urge OIG to Create Anti-Kickback Safe Harbor for Clinical Trial Participant Expenses
The American Cancer Society Cancer Action Network and 128 other advocacy and professional groups submitted a comment letter to HHS OIG on August 24, 2026, requesting a new safe harbor under the federal anti-kickback statute. The proposed safe harbor would allow clinical trial sponsors to cover participants' travel, lodging, and other expenses without exposure to fraud and abuse liability. The comment period timing suggests OIG is considering rulemaking on this issue. For Medicaid providers participating in clinical trials, this matters because current anti-kickback constraints limit their ability to cover beneficiary costs, potentially reducing trial participation among Medicaid populations who face the greatest financial barriers to access.
- Legal · FL
DOJ Settles with Complete Health MSO for $14.1M Over Compliance Allegations
The Department of Justice announced a $14.1 million settlement with Complete Health Partners Holdings, a Florida management services organization, to resolve allegations under the False Claims Act. The settlement, finalized August 4, 2026, addresses compliance failures at the MSO level that likely involve arrangements affecting federal health programs. The case highlights enforcement risks for management services organizations operating in or adjacent to Medicaid managed care markets. Specific compliance program deficiencies leading to the settlement offer instructive lessons for MSOs, Medicaid health plans, and affiliated provider organizations subject to federal fraud and abuse laws.
Tuesday, August 25 · 3 stories
- Legal · NV
Nevada Attorney General Declined Majority of Medicaid Fraud Referrals
Nevada Attorney General Aaron Ford's office declined more than half of Medicaid fraud referrals it received, according to reporting examining his prosecution record as he campaigns for governor. Ford defends his office's prosecution rate as high, stating many referrals lack sufficient evidence to pursue criminal charges. The article examines claims made in political advertisements criticizing Ford's handling of Medicaid fraud enforcement. This review comes as states face increasing scrutiny over program integrity and fraud prevention efforts.
- Legal
OIG Eliminates Prior Approval Requirement for State Medicaid Fraud Unit Data Mining
On August 13, 2026, HHS OIG issued State Fraud Policy Transmittal No. 2026-1 eliminating the federal approval requirement that previously required Medicaid Fraud Control Units to obtain OIG permission before conducting federally funded data mining on Medicaid claims. MFCUs also no longer need to renew approvals every three years. The change took effect immediately upon issuance. The policy shift gives state fraud units greater operational flexibility to deploy analytics tools against potentially fraudulent Medicaid billing without navigating a federal checkpoint, potentially accelerating fraud detection and investigation timelines.
- Legal
Home Health Providers Emphasize Compliance Amid CMS and DOJ Fraud Enforcement
VNA Health Group and Empath Health are reinforcing quality documentation, oversight, and compliance protocols in response to intensified anti-fraud enforcement by CMS and the Department of Justice targeting the home health industry. The providers report focusing on communication strategies to clarify their existing compliance models as enforcement activity increases. The crackdown affects home health agencies providing services under Medicare and Medicaid, with providers emphasizing documentation integrity and proactive oversight to mitigate fraud and abuse risk.
Monday, August 24 · 1 story
- Legal
Federal Court Ruling on Medicaid Transgender Care Could Restrict Other Drug Coverage
A federal court decision restricting Medicaid coverage of gender-affirming care for minors establishes legal precedent that could extend beyond transgender care, according to legal experts. The ruling's legal framework — which allows states to exclude specific treatments from Medicaid coverage based on medical necessity determinations — may be applied to restrict coverage of other drugs and services. State Medicaid agencies and managed care plans should monitor whether this precedent affects coverage requirements for treatments beyond gender-affirming care, particularly those subject to state-level medical necessity debates.
Friday, August 21 · 2 stories
- Legal · NJ
Business Groups Sue New Jersey Over Employer Fines for Workers on Medicaid
Business organizations have filed suit challenging a New Jersey law that imposes fines on large employers whose workers are enrolled in Medicaid. The plaintiffs argue the statute violates federal privacy laws by requiring employers to inquire about workers' health insurance status. The lawsuit seeks to void the law before it takes effect. The case could affect state efforts to shift Medicaid costs to employers and has implications for how states structure employer responsibility provisions in health coverage programs.
- Legal
DOJ Issues Rule Reversing 25-Year Interpretation of ADA Olmstead Requirements
The Department of Justice has issued a new rule reversing its longstanding interpretation of the Americans with Disabilities Act's integration mandate under Olmstead v. L.C. The rule could allow states to scale back home- and community-based services that enable disabled individuals to avoid institutional care. The change takes effect immediately upon publication. This matters for state Medicaid agencies and LTSS providers because the Olmstead decision has driven HCBS expansion for decades — weakening federal enforcement of the integration mandate gives states new latitude to reduce HCBS funding or waitlist remediation without DOJ intervention.
Thursday, August 20 · 4 stories
- Legal
Federal Court Decertifies 11 Clinics from 340B Program in Drugmaker Lawsuit
A federal district court in Washington, D.C. granted partial summary judgment to drugmakers including Amgen and Genentech on August 14, 2026, ordering 11 clinics' 340B certifications set aside for failing to meet statutory participation requirements. The ruling addresses longstanding disputes between drugmakers and covered entities over 340B program eligibility. The decision affects clinic access to discounted drugs under the 340B program and may signal stricter judicial scrutiny of covered entity qualifications.
- Legal
Federal Court Blocks Trump Administration Changes to Teen Pregnancy Prevention Grants
A federal district court in Washington, D.C., issued a temporary injunction halting the Trump administration's changes to the Teen Pregnancy Prevention (TPP) program that cut tens of millions in federal grants. The order pauses the administration's changes pending further litigation. The ruling affects organizations that lost federal funding abruptly under the policy shift. The injunction takes effect immediately.
- Legal · IA
Iowa Attorney Sanctioned for Medicaid Fraud Scheme Involving Asset Transfers
Timothy Mark Anderson, a Garner, Iowa attorney, faces state licensing sanctions following his October 2025 conviction for false statements relating to a health care matter in a Medicaid fraud scheme. Anderson attempted to help a client qualify for Medicaid by improperly transferring assets, including involvement with a Rolls Royce. The case illustrates enforcement actions against professionals who assist in Medicaid eligibility fraud through improper asset sheltering or transfer schemes. State licensing sanctions follow the federal conviction, affecting Anderson's ability to practice law.
- Legal · NY
New York Strengthens Medicaid Anti-Fraud Controls Under Federal Scrutiny
New York's Department of Health has adopted new program administrative measures to address federal concerns about oversight and compliance integrity in its Medicaid program, particularly for personal care and home health providers. The measures come as HHS scrutinizes the state for perceived gaps in program integrity controls. The changes appear designed to strengthen provider oversight and fraud prevention mechanisms in response to federal pressure. This development signals heightened compliance expectations for providers in these sectors and potential model requirements other states may face.