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Wednesday, July 8 · 1 story
- Legal
Four Major Pharmacy Litigation Tracks Progress: PBM Ownership, 340B, Antitrust, Fraud
Pharmacy litigation is proceeding on four major fronts. State laws banning PBM ownership of pharmacies face constitutional challenges. Drugmakers are challenging state 340B protections in multiple jurisdictions. PBMs face antitrust claims over reimbursement practices. Federal fraud enforcement actions target rebate and claims manipulation by PBMs. These cases are ongoing with varying timelines across federal and state courts.
Tuesday, July 7 · 3 stories
- Legal
5,000 Independent Pharmacies Sue Prime Therapeutics for Alleged Antitrust Violations
Nearly 5,000 independent pharmacies filed a federal antitrust lawsuit on July 2, 2026, in the U.S. District Court for the Western District of Washington against Prime Therapeutics, alleging the PBM conspired with Express Scripts to suppress pharmacy reimbursement rates and increase fees. The complaint claims violations of federal antitrust law through coordinated pricing practices. The lawsuit targets PBM reimbursement methodologies that affect pharmacy network economics. This litigation follows broader scrutiny of PBM pricing practices and their impact on pharmacy access.
- Legal · NY
HHS-OIG Denies Recertification for New York Medicaid Fraud Control Unit, Freezes $60 Million
The HHS Office of Inspector General denied recertification for New York's Medicaid Fraud Control Unit and froze $60 million in annual federal funds effective July 1, 2026. This action came one week after DOJ's National Health Care Fraud Takedown announced partnerships with all 50 state MFCUs. The denial represents an unprecedented enforcement step against a state fraud control unit that typically partners with federal authorities on Medicaid provider fraud investigations. For Medicaid managed care organizations in New York, this creates uncertainty around ongoing fraud investigations, referral processes, and coordination with state enforcement authorities on provider integrity matters.
- Legal · NY
PPL Reaches $162M Settlement Over New York CDPAP Payroll Violations
A federal judge preliminarily approved a $162 million class action settlement with approximately 200,000 home care workers alleging payroll and benefits violations following New York's transition of its Medicaid-funded Consumer Directed Personal Assistance Program (CDPAP) to a single fiscal intermediary, Public Partnerships LLC (PPL). The settlement addresses claims arising from the state's consolidation of CDPAP fiscal intermediary services. The approval comes weeks after DOJ involvement in related matters. Final approval is pending.
Monday, July 6 · 1 story
- Legal
CMS Payment Suspensions for Fraud or Overpayment Trigger Compliance Requirements
CMS can temporarily suspend Medicare and Medicaid payments to providers when evidence of overpayment or suspected fraud exists. While suspensions are temporary, they create immediate financial pressure and can lead to exclusion if providers fail to achieve compliance. The suspension authority applies to both fee-for-service and managed care contexts when credible allegations of fraud arise. Providers facing suspension must respond quickly to CMS documentation requests and implement corrective action plans to avoid permanent exclusion from federal healthcare programs.
Friday, July 3 · 1 story
- Legal
DOJ, CMS, OIG Detail Heightened Health Care Fraud Enforcement at AHLA Annual Meeting
Federal enforcement officials from the Department of Justice, Centers for Medicare & Medicaid Services, and the HHS Office of Inspector General outlined intensified fraud and abuse enforcement initiatives at the American Health Law Association's Annual Meeting in New York on July 3, 2026. The agencies described their coordinated approach to health care fraud investigations and prosecutions affecting providers and health plans. The remarks signal continued aggressive enforcement activity through 2026 and beyond. Medicaid managed care organizations should expect heightened scrutiny of billing practices, network arrangements, and compliance programs as federal agencies expand investigative resources and coordination.
Thursday, July 2 · 3 stories
- Legal · CO
Federal Judge Blocks Colorado Drug Affordability Board Price Cap on Amgen's Enbrel
A federal judge has blocked Colorado's Drug Affordability Board from implementing a price cap on Amgen's Enbrel, a blockbuster rheumatoid arthritis medication. The ruling prevents the state board from enforcing its pricing limit on the drug. The decision affects Colorado's ability to use its drug affordability review process to control costs for high-priced medications. This represents a significant setback for state efforts to directly regulate pharmaceutical pricing through affordability boards, with implications for how states can address drug costs in Medicaid programs.
- Legal
Federal Court Dismisses PBM Lawsuit Against FTC After Insulin Price Settlements
A federal court has dismissed a lawsuit filed by Express Scripts, CVS Caremark, and Optum Rx against the Federal Trade Commission. The three pharmacy benefit managers had sued the FTC after the agency accused them of inflating insulin costs, but the case is now closed following settlements between the PBMs and regulators. The settlements resolve the FTC's allegations regarding the PBMs' role in insulin pricing practices. The dismissal comes after the parties reached resolution on the underlying insulin pricing dispute.
- Legal
DOJ Charges 455 Defendants in 2026 Health Care Fraud Takedown Targeting Medicaid
On June 23, 2026, the Department of Justice announced criminal charges against 455 defendants, including approximately 90 licensed medical professionals, connected to more than $6.5 billion in alleged false claims. DOJ characterized this as the largest coordinated health care fraud enforcement action in its history and emphasized a renewed focus on Medicaid fraud cases. The takedown included enforcement actions in Virginia and multiple other states. Charges took effect immediately upon announcement, with defendants facing federal prosecution.
Wednesday, July 1 · 1 story
- Legal · NY
HHS OIG Suspends Federal Funding to New York Medicaid Fraud Unit
The HHS Office of Inspector General notified New York on June 30 that federal grant funds to the state's Medicaid fraud control unit are suspended effective July 1, 2026. The unit receives approximately $60 million annually in federal funding. The suspension affects the state's capacity to investigate and prosecute Medicaid fraud, including cases involving managed care organizations. No end date for the suspension was specified in the OIG letter.
Tuesday, June 30 · 3 stories
- Legal · TX
AstraZeneca Pays $34 Million to Settle Texas Medicaid Kickback Claims
AstraZeneca agreed to pay $34 million to resolve allegations brought by the Texas Attorney General that the company paid kickbacks to improperly influence prescriptions reimbursed by Texas Medicaid. The settlement resolves claims that the pharmaceutical manufacturer violated anti-kickback statutes through payments that influenced prescribing behavior for drugs covered under the state's Medicaid program. The settlement does not include an admission of liability but ends the state's enforcement action against the company.
- Legal · PA
Pennsylvania Joins Multi-State Lawsuit Challenging Federal Medicaid Work Requirement Rules
Pennsylvania has joined a multi-state lawsuit against the Trump administration over new Medicaid work requirement rules. The litigation challenges federal restrictions on how states can handle applicants deemed medically frail, a term that lacks a standardized definition in Medicaid policy. The lawsuit represents a coordinated state effort to block implementation of the work requirement framework. This legal action creates compliance uncertainty for managed care organizations operating in participating states as they await court resolution on exemption criteria and enrollment procedures.
- Legal · MS
Mississippi Judge Orders Emergency Medicaid Payment to Prevent Hospital Closure
A judge has ordered Mississippi Medicaid officials to make an emergency payment to Greenwood Leflore Hospital to prevent its imminent closure this week. The Delta hospital argued that without the payment, it would be forced to shut down, threatening a proposed agreement for the University of Mississippi Medical Center to assume operations. The court intervention ensures continued access to hospital services in the region while the UMMC takeover arrangement moves forward. The case highlights the acute financial pressures facing rural hospitals dependent on Medicaid reimbursement.
Monday, June 29 · 1 story
- Legal
DOJ Antitrust Settlements Target Hospital Steering Restrictions in Commercial Payer Contracts
The U.S. Department of Justice Antitrust Division filed civil complaints against hospital systems for using contract provisions that require health insurers to include them in nearly all commercial networks at preferred benefit tiers. These steering restrictions limit insurers' ability to design narrow network products. The OhioHealth settlement reflects DOJ's increased enforcement focus on payer contracting practices that constrain network design flexibility. While the cases involve commercial insurance, the enforcement trend signals heightened scrutiny of similar anti-steering and anti-tiering provisions that may appear in Medicaid managed care contracts.
Friday, June 26 · 2 stories
- Legal
Federal Court Orders Unsealing of Decade-Old False Claims Act Filings in HCR ManorCare Case
A federal court in Pennsylvania ordered the unsealing of nearly ten years of False Claims Act filings in U.S. ex rel. Compton v. HCR ManorCare, Inc., ruling that the government failed to justify continued sealing under the strong presumption of public access to judicial records. The decision, issued April 17, 2026, requires disclosure of qui tam complaint materials that have been under seal since 2016. The ruling reflects growing judicial scrutiny of extended seal periods in FCA cases, which typically remain sealed while the government investigates allegations of fraud against federal health programs including Medicaid.
- Legal
UPIC Audits Target Medicare and Medicaid Provider Billing Compliance
Unified Program Integrity Contractors (UPICs) are CMS-hired auditors that review healthcare provider medical and billing records to identify improper payments and pursue recoupments in Medicare and Medicaid programs. UPICs operate as part of CMS's broader program integrity enforcement infrastructure. The article provides a procedural overview for providers facing UPIC audits, covering response strategies and compliance steps. This guidance is relevant for any Medicaid managed care organization or provider subject to program integrity review.
Thursday, June 25 · 2 stories
- Legal
Court Permits End to TPS Protections for Syrian and Haitian Nationals
A federal court ruled that the Trump administration may terminate Temporary Protected Status (TPS) for nationals from Syria and Haiti. The decision affects approximately 7,000 Haitians and 6,700 Syrians currently residing in the U.S. under TPS. The ruling follows years of litigation challenging the administration's 2018 decision to end these protections. Affected individuals will face potential deportation unless they adjust their immigration status through other means or Congress acts to provide alternative relief.
- Legal · NY
Federal Judge Blocks DOJ Subpoenas for Transgender Patient Records at NYC Hospitals
A federal district court issued a temporary restraining order blocking the Justice Department from obtaining medical records of transgender patients treated at New York City hospitals. The ruling halts an ongoing DOJ investigation into gender-affirming care provided at these facilities. The order provides immediate protection for patient records while the case proceeds. The decision affects hospitals treating Medicaid beneficiaries receiving gender-affirming services and raises questions about federal enforcement priorities and patient privacy protections.
Wednesday, June 24 · 2 stories
- Legal · FL
Florida Pediatric Provider Sues State Over ABA Rate Methodology in Medicaid Managed Care
Pediatric Associates, Florida's largest Medicaid pediatric provider, filed suit against the DeSantis administration challenging how the state adjusted managed care capitation rates to account for applied behavioral analysis (ABA) services for children with autism and special needs. The lawsuit alleges Florida Medicaid officials improperly calculated rate adjustments when incorporating ABA costs into managed care plan payments. The case directly challenges the state's rate-setting methodology for pediatric behavioral health services delivered through managed care organizations. Litigation outcome could affect how Florida structures capitation payments for high-cost behavioral health services and whether current rates adequately cover provider costs.
- Legal · IA
Iowa Pharmacy Sues State Over Unpaid Medicaid Claims, Alleges Unsupported Fraud Charges
Rashid Pharmacy in Fort Madison has filed a lawsuit seeking judicial review of a May 22, 2026 order by the Iowa Department of Health and Human Services regarding millions of dollars in unpaid Medicaid pharmaceutical claims. The pharmacy alleges the state made unsupported fraud accusations while withholding payment. The case involves Iowa Medicaid Enterprise's oversight authority and payment dispute resolution procedures. The outcome could affect how Iowa handles pharmacy payment disputes and fraud allegations.