Monday, May 25, 2026

Aetna agreed to a $117.7 million settlement to resolve allegations of submitting false claims to the Medicare Advantage program. The agreement resolves claims that the insurer submitted inaccurate diagnostic data to inflate risk-adjusted payments from CMS. This enforcement action signals continued DOJ and OIG scrutiny of MA coding and risk adjustment practices. While no direct practice action is required, this settlement reinforces the compliance environment surrounding Medicare Advantage contracts and risk-adjustment data submission.

Medicare beneficiaries seeking coverage for GLP-1 drugs like semaglutide solely for weight loss received confirmation that these claims will continue to be denied under current Part D policy. This clarification follows recent coverage expansion for patients with type 2 diabetes and cardiovascular disease. Practices administering GLP-1s must ensure proper diagnostic coding aligns with covered indications (e.g., E11.9 for diabetes) and verify prior authorization requirements. For cash-pay weight loss services, update patient financial responsibility forms and provide clear cost estimates to avoid unexpected balances.

RCM firm Medtransic launched a dedicated mental health billing division to address the specialty's persistently high claim denial rates. The move highlights systemic payer challenges in behavioral health, including complex medical necessity reviews, frequent prior auth requirements, and restrictive visit limits. Behavioral health practices should review their current denial management processes for services like psychotherapy and psychiatric evaluations. Monitor payer-specific behavioral health policies and consider whether specialized RCM support could improve clean claim rates and reduce administrative burden.

Maryland legislators have introduced a first-of-its-kind bill to cap patient out-of-pocket costs for GLP-1 medications such as Ozempic and Wegovy. The proposal targets the financial barrier to access for weight-loss and diabetes drugs, which are seeing skyrocketing demand and insurer denials. This state-level action directly challenges the commercial payer trend of imposing high copays and prior authorization hurdles. If enacted, it could establish a model for other states to follow and force Medicaid and commercial plans to adjust their pharmacy benefit designs. Monitor the bill's progress through the Maryland General Assembly; a win would likely trigger similar efforts in neighboring states.

President Trump stated Medicare will begin covering GLP-1 medications for weight loss starting July 1, 2026. This represents a major policy shift, as Medicare currently covers these drugs only for Type 2 diabetes, not for obesity alone. If implemented via CMS rulemaking, it would open coverage to millions of Medicare beneficiaries and require updates to Part D plan formularies. Practices should prepare for a surge in patient inquiries and potential prior authorization requirements for this new indication. Verify the final CMS guidance and any associated National Coverage Determination before July 1 to confirm the exact coverage criteria and billing rules.