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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.
Wednesday, August 19 · 2 stories
- Legal
Federal Judge Vacates Trump Administration Restrictions on ACA Gender-Affirming Care
A federal judge has struck down Trump administration restrictions on gender-affirming care under the Affordable Care Act while upholding other ACA policy changes. The ruling restores certain protections for gender-affirming care that had been rolled back by the administration. The decision affects coverage requirements for Medicaid managed care organizations and state agencies operating under ACA-aligned nondiscrimination standards. The ruling takes effect immediately, though appeals are likely.
- Legal · MA
Massachusetts Medicaid Transportation Vendor Contests Fraud Charges, Cites Broker Recordkeeping Failures
A defendant charged with defrauding MassHealth's non-emergency medical transportation (NEMT) program is contesting the allegations, attributing billing discrepancies to inadequate recordkeeping by brokers and vendors managing scheduling, patient records, and billing for Medicaid-covered rides. The case highlights operational weaknesses in the NEMT broker infrastructure that supports ride services for MassHealth members. The defense strategy suggests systemic documentation problems may complicate fraud prosecution and raise questions about broker oversight and accountability in Massachusetts' NEMT program.
Tuesday, August 18 · 1 story
- Legal
Democratic Senators Accuse HHS of Violating Court Order on Medicaid Data Sharing with ICE
Four Democratic senators accused the Trump administration of violating a court order by continuing to share Medicaid enrollment data with DHS and ICE for deportation proceedings. Sens. Wyden, Booker, Merkley, and Van Hollen demanded HHS immediately halt the data sharing practice. The complaint alleges ongoing transfers of beneficiary information despite judicial restrictions. The disclosure raises compliance and enrollment concerns for state Medicaid agencies managing beneficiary data and MCOs responsible for protecting member information under privacy regulations.
Monday, August 17 · 2 stories
- Legal
Shareholders Sue UnitedHealth Over Change Healthcare Cyberattack and Medicare Audit Failures
Two shareholder groups filed suit alleging UnitedHealth misled investors and ignored cybersecurity vulnerabilities that enabled the Change Healthcare cyberattack, and separately shuttered an internal Medicare billing audit. The complaint claims UnitedHealth failed to address known governance and security gaps. The lawsuit seeks damages for investor losses tied to these alleged failures. The case adds legal pressure on UnitedHealth following the massive cyberattack that disrupted claims processing across the healthcare system.
- Legal
OIG Approves FQHC Produce Benefits for Patients with Chronic Conditions
The HHS Office of Inspector General issued Advisory Opinion 26-16 approving a federally qualified health center's program to provide produce boxes and vouchers to patients with certain chronic health conditions. The arrangement would typically constitute prohibited remuneration under the Beneficiary Inducements Civil Monetary Penalty statute, but OIG determined it qualifies for protection. The opinion provides compliance guidance for FQHCs and other Medicaid providers seeking to implement food-as-medicine interventions without triggering anti-kickback or beneficiary inducement penalties.
Saturday, August 15 · 1 story
- Legal
DOJ Fraud Division Targets Home Health and Hospice with Data-Driven Enforcement
The Department of Justice Fraud Division identified home health and hospice as top enforcement priorities in a Thursday memorandum, signaling intensified scrutiny of these sectors. The agency plans to deploy advanced data analysis techniques to detect fraud schemes and increase staffing for healthcare fraud investigations. The directive takes effect immediately as DOJ resource allocation shifts toward these provider types. This matters for Medicaid managed care plans and state agencies because home- and community-based services, including home health and hospice, represent significant portions of LTSS spending, and heightened federal fraud enforcement will likely require enhanced provider credentialing, claims auditing, and program integrity protocols.
Friday, August 14 · 5 stories
- Legal
Patient Advocacy Group Sues AMA Over CPT Code Copyright
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.
- Legal
Fifth Circuit Invalidates No Surprises Act Benchmark Calculation Methods
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.
- Legal
Hospice Disenrollment Affects 1 in 16 Patients Who Improve
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.
- Legal
DOJ’s 2026 Health Care Fraud Takedown Signals Medicaid Enforcement Priorities
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.
- Legal
Federal Government Refers Hospitals, PBMs to DOJ Over Gender-Affirming Care Billing
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.
Thursday, August 13 · 1 story
- Legal · FL
Federal Appeals Court Questions Florida Medicaid Redetermination Process in Oral Arguments
A three-judge federal appeals panel questioned Florida officials during oral arguments over the state's Medicaid termination procedures following the end of the COVID-19 public health emergency. The lawsuit, filed three years ago, challenges how Florida conducted eligibility redeterminations and disenrolled beneficiaries after continuous enrollment protections expired. The court's scrutiny focused on the state's procedural compliance with federal notice and due process requirements. The case could affect how states manage Medicaid disenrollment processes and beneficiary protections during eligibility reviews.
Tuesday, August 11 · 2 stories
- Legal
Drug Manufacturers Challenge State 340B Contract Pharmacy Laws in Illinois, South Dakota
AbbVie and Novartis filed suit against Illinois on August 7, 2026, seeking to block the state's new 340B contract pharmacy law. Three days later, a federal judge in South Dakota dismissed three separate lawsuits from AbbVie, AstraZeneca, and PhRMA challenging South Dakota's similar law. The legal battles center on state efforts to require drug manufacturers to honor 340B pricing at contract pharmacies. The outcome will determine whether states can enforce 340B contract pharmacy requirements against manufacturer restrictions.
- Legal · SD
Federal Judge Upholds South Dakota Drug Discount Law for Rural Providers
A federal judge dismissed legal challenges to South Dakota legislation allowing rural healthcare providers to purchase discounted drugs and mark up sale prices to offset low Medicare and Medicaid reimbursement. AbbVie, manufacturer of Humira, sued the state in April 2025 challenging the law. The ruling takes effect immediately with the dismissal of the pharmaceutical manufacturer's lawsuit. The decision matters for rural providers in South Dakota who rely on drug discount programs to sustain operations amid inadequate Medicaid payment rates.
Monday, August 10 · 3 stories
- Legal · IA
Iowa Therapist Retains License Despite Fraud and Theft Convictions
The Iowa Board of Behavioral Health Professionals allowed Michelle Raye Stewart-Sandusky, a state-licensed marital and family therapist, to retain her license despite January 2026 convictions for business-related theft, fraud, and forgery. The board had charged her with offenses directly related to professional duties and responsibilities. The decision appears final as of August 2026. The case affects Medicaid provider enrollment standards and credentialing requirements for behavioral health professionals in managed care networks.
- Legal
CMS Releases ABA Toolkit as Federal Enforcement Targets Autism Therapy Providers
CMS has released a new Applied Behavior Analysis toolkit amid increasing federal enforcement scrutiny of autism therapy providers. The development coincides with congressional investigations into the ABA therapy industry. The toolkit and enforcement actions reflect heightened government attention to billing practices, medical necessity determinations, and compliance issues in the autism therapy sector. State Medicaid agencies, managed care organizations, and ABA providers face increased program integrity oversight as federal authorities target potential fraud and abuse in this growing service area.