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Thursday, July 23 · 1 story
- Legal
DOJ Secures Six Healthcare Fraud Convictions in Three Weeks, $1.1B in Alleged Losses
The Department of Justice's National Fraud Enforcement Division obtained six jury trial convictions between May 13 and June 1, 2026, across five federal districts. The defendants include a software platform executive and a rural nurse practitioner, among others spanning multiple healthcare settings. Total alleged losses exceed $1.1 billion to Medicare, Medicaid, and other health benefit programs. The convictions demonstrate DOJ's sustained enforcement activity across the healthcare sector, with direct implications for Medicaid managed care organizations' fraud, waste, and abuse compliance programs.
Wednesday, July 22 · 3 stories
- Legal · TX
AstraZeneca Pays Texas $34M to Settle Medicaid Kickback Claims
AstraZeneca Pharmaceuticals LP agreed to pay $33,998,000 to Texas to resolve allegations that it provided illegal remuneration to healthcare providers in connection with prescriptions for drugs covered by the state's Medicaid program. The settlement addresses potential violations of anti-kickback statutes related to inducements tied to Medicaid prescribing. Texas Medicaid managed care organizations that reimbursed claims for the implicated drugs during the alleged period may have paid inflated costs tied to these arrangements. The settlement follows state enforcement action under Texas Medicaid fraud statutes.
- Legal
D.C. Circuit Rules Drugmakers Need HHS Approval for 340B Rebate Models
The U.S. Court of Appeals for the D.C. Circuit ruled July 21, 2026, that pharmaceutical manufacturers cannot implement 340B rebate models without prior approval from the HHS secretary. The decision upheld lower court rulings against Novartis, Johnson & Johnson Health Care Systems, Bristol Myers Squibb, and Eli Lilly. The ruling reinforces federal authority over 340B program administration and blocks manufacturer attempts to unilaterally restructure drug discount delivery mechanisms. For Medicaid managed care organizations with provider networks that include 340B-eligible entities, the decision preserves existing 340B purchasing pathways and prevents disruption to contract pharmacy arrangements that affect covered entity participation and pharmacy network stability.
- Legal
23 States Sue CMS Over Medicaid Work Requirements Rule Exemptions
On June 29, 2026, twenty-three states, two governors, and the District of Columbia filed suit in U.S. District Court for Massachusetts challenging CMS implementation of Medicaid work requirements under the One Big Beautiful Bill Act. Plaintiffs allege CMS unlawfully narrowed exemptions for medically frail beneficiaries. The litigation seeks to block enforcement of the work requirements rule pending judicial review. This lawsuit directly affects managed care organizations responsible for identifying medically frail populations, verifying exemptions, and ensuring compliance with work requirement reporting.
Monday, July 20 · 1 story
- Legal
Federal Judge Blocks CMS Rule Expanding Catastrophic ACA Plans
A federal judge issued a stay Thursday halting implementation of a CMS final rule that would have expanded access to catastrophic health plans in the ACA marketplace. The court found the policies were likely to increase costs and reduce access to comprehensive coverage. The ruling blocks the administration's changes pending further litigation. While the decision directly affects the ACA individual market, Medicaid managed care organizations operating in dual or integrated programs may see indirect effects on coverage transitions and risk pool composition.
Friday, July 17 · 1 story
- Legal · NY
New York Ambulette Owners Indicted for Medicaid Transportation Fraud and Kickbacks
Two New York residents face federal charges in the Eastern District of New York for conspiracy to commit healthcare fraud related to Medicaid transportation services. The defendants allegedly paid kickbacks and submitted fraudulent claims to Medicaid and other government payors for ambulette services that were either not provided or included inflated mileage. The indictment was filed in federal court in Central Islip. The case demonstrates ongoing federal enforcement activity targeting non-emergency medical transportation fraud schemes.
Thursday, July 16 · 2 stories
- Legal · NV
Nevada AG Prosecutes 40% of Medicaid Fraud Referrals, Double National Average
Nevada Attorney General Aaron Ford prosecutes 40% of Medicaid fraud referrals received by his office, double the national average for state attorneys general, according to federal data. The prosecution rate has drawn criticism from Governor Joe Lombardo and state legislators who argue the acceptance rate is too low. The data indicates Nevada's fraud enforcement activity significantly exceeds typical state performance, though a substantial majority of referrals still do not result in prosecution. This reflects broader challenges states face in Medicaid program integrity enforcement.
- Legal
CMS and OIG Increase Payment Suspensions Against Home Health Agencies
The Centers for Medicare & Medicaid Services and HHS Office of Inspector General are escalating enforcement actions against home healthcare providers suspected of fraud, including payment suspensions, recoupments, and criminal prosecution. Both Medicare and Medicaid suspensions are being deployed more frequently against home health agencies. The article outlines procedural steps for providers facing suspension. This enforcement trend affects Medicaid managed care organizations that contract with home health agencies and rely on them for post-acute and long-term services and supports delivery.
Wednesday, July 15 · 2 stories
- Legal
Glenmark Settles State Price-Fixing Claims for $29.6 Million
Glenmark Pharmaceuticals agreed to pay $29.6 million to settle price-fixing allegations brought by multiple states. The settlement resolves a multi-year investigation into alleged anti-competitive conduct involving drug pricing. The agreement covers claims from dozens of states that alleged Glenmark engaged in collusion to fix prices on generic pharmaceuticals. This settlement follows a pattern of similar enforcement actions against generic drug manufacturers over the past several years.
- Legal
OIG Releases Updated Corporate Integrity Agreement Template with Enhanced Compliance Requirements
On April 30, 2026, the HHS Office of Inspector General unveiled a revised Corporate Integrity Agreement template at the Health Care Compliance Association's annual conference, using the Kinex Medical Company CIA as the model. The updated template retains core compliance program elements while introducing enhanced compliance obligations for health care organizations entering into settlement agreements with OIG. CIAs are typically imposed on providers and health plans that resolve fraud and abuse allegations, requiring heightened compliance measures for three to five years. The new template will apply to future CIA settlements and affects any Medicaid managed care organization facing potential OIG enforcement actions.
Tuesday, July 14 · 3 stories
- Legal
National Health Law Program Examines Crisis Pregnancy Center Medicaid Billing Practices
The National Health Law Program has published analysis examining the relationship between crisis pregnancy centers and Medicaid reimbursement. CPCs, which typically do not provide abortion, contraception, or comprehensive reproductive health services, may seek Medicaid payment for limited services such as pregnancy tests and ultrasounds. The analysis raises questions about billing practices, scope of services, and regulatory oversight of these facilities within Medicaid programs. The issue affects managed care organizations that may receive claims from CPCs or face questions about network adequacy and covered services for reproductive health.
- Legal
HHS Section 504 Rule Mandates Accessible Medical Diagnostic Equipment for Medicaid-Funded Providers
The U.S. Department of Health and Human Services published a final rule in May 2024 revising Section 504 of the Rehabilitation Act of 1973, which is now in effect. The rule requires healthcare systems receiving federal financial assistance, including Medicaid funding, to ensure medical diagnostic equipment is accessible to patients with disabilities. All entities that accept Medicaid payments are subject to these nondiscrimination requirements. The regulation imposes new compliance obligations on providers and health systems that contract with Medicaid managed care organizations.
- Legal
HHS OIG Excludes Over 1,200 People and Entities from Federal Programs in Six Months
The HHS Office of Inspector General excluded more than 1,200 individuals and entities from participating in federal healthcare programs between October 2025 and March 2026. The exclusions are part of increased enforcement activity under the Trump administration targeting fraud in Medicaid and Medicare Advantage. Excluded providers and entities cannot receive payment from federal programs, and managed care organizations are prohibited from contracting with or employing excluded individuals. MCOs must screen their networks against the OIG exclusion list monthly to maintain compliance and avoid penalties.
Monday, July 13 · 3 stories
- Legal
Idaho AG Requests Expanded Medicaid Data Access for Fraud Investigations at White House Roundtable
Idaho Attorney General Raúl Labrador asked Vice President JD Vance and federal officials on Tuesday for broader access to Medicaid data to support fraud investigation and recovery efforts. Labrador participated in a White House roundtable with Federal Trade Commission Chairman Andrew Ferguson, White House Deputy Chief of Staff Stephen Miller, and attorneys general from 14 other states. The request signals potential federal policy movement toward expanded state AG access to Medicaid claims and enrollment data for program integrity purposes. No immediate action or timeline was announced.
- Legal
CMS Revises Medicare Overpayment Rule on Identification Timeline and Investigation Requirements
CMS has revised regulations governing Medicare and Medicaid overpayments, modifying the definition of when an overpayment is considered "identified" and updating requirements for investigating related overpayments. The revisions affect how providers determine the 60-day deadline to report and return overpayments under the Affordable Care Act. While the changes offer some additional flexibility in compliance timelines, they reinforce the need for robust internal auditing and monitoring systems. Failure to comply with revised timelines and investigation standards may result in False Claims Act liability and other enforcement actions.
- Legal
Bankrupt Omnicare Settles DOJ Fraud Case for $440 Million
Omnicare has reached a $440 million settlement with the Department of Justice to resolve fraud charges related to improper billing of government health programs. The settlement follows Omnicare's bankruptcy filing last year after a court ordered the company to pay nearly $950 million for fraudulent billing practices. The reduced settlement amount reflects negotiations during the bankruptcy process. The case represents one of the largest False Claims Act settlements in the pharmacy services sector and concludes years of litigation over alleged improper billing to Medicaid and Medicare.
Friday, July 10 · 3 stories
- Legal · NH
Federal Trial Set for November on New Hampshire LTSS Program ADA Compliance
A federal judge has scheduled a November 2026 trial to determine whether New Hampshire's Choices for Independence program violates federal law by failing to provide adequate home and community-based services for elderly individuals and people with physical disabilities. The case centers on allegations that the state's LTSS program forces beneficiaries into institutional settings in violation of the Americans with Disabilities Act and the Supreme Court's Olmstead decision. The trial outcome could establish precedent for evaluating HCBS adequacy and state compliance with federal integration mandates. U.S. District Judge Paul Barbadoro will hear evidence on whether the program meets federal standards for community-based care.
- Legal · OH
Federal and Ohio Officials Highlight Individual Medicaid Fraud Cases While Corporate Enforcement Lags
In early June 2026, Trump administration officials traveled to Ohio to publicize investigations into individuals suspected of Medicaid fraud totaling tens of millions of dollars. The enforcement focus excluded corporate contractors holding large state Medicaid contracts, despite recent lawsuits against several companies and two settlements. The disparity raises questions about enforcement priorities when corporate entities with substantial Medicaid business face fraud allegations but receive less public attention than individual providers. The timing and scope of corporate enforcement actions remain unclear.
- Legal · NC
North Carolina Woman Pleads Guilty to $1.7 Million Medicaid Urine Testing Fraud
A North Carolina woman pleaded guilty to defrauding Medicaid of $1.7 million through fraudulent urine testing claims. The scheme involved billing for unnecessary or unperformed laboratory testing services. The case represents ongoing federal and state enforcement activity targeting laboratory billing fraud in Medicaid programs. Medicaid managed care organizations that reimburse laboratory services should review utilization patterns and billing practices for urine drug testing to identify potential fraud.
Thursday, July 9 · 1 story
- Legal
Court Dismisses False Claims Act Case on Medicare Advantage Marketing Practices
A federal court dismissed a sealed False Claims Act case alleging Medicare Advantage marketing violations. The relator attempted to characterize patient acquisition and outreach activities as fraudulent claims for payment. The dismissal demonstrates judicial skepticism toward FCA theories targeting marketing conduct rather than false billing. The outcome matters for Medicare Advantage plans facing similar qui tam allegations linking enrollment practices to improper payment.