Tuesday, June 2, 2026

The Massachusetts Attorney General has filed a lawsuit against UnitedHealthcare alleging a long-running scheme to defraud MassHealth. The state claims UHC used a subsidiary to submit fraudulent diagnosis codes and inflate risk-adjustment scores for Medicaid members, extracting over $50 million in improper payments. This lawsuit signals a more aggressive posture from state Medicaid agencies against payer practices. Monitor this case as it progresses; the outcome could influence how Medicaid managed-care plans are audited and could prompt similar enforcement in other states.

CMS has published final guidance for states that choose to impose work and community-engagement requirements on certain Medicaid beneficiaries. The rule sets minimum standards for exemptions, verification processes, and hardship criteria. For practices in states like Florida, Georgia, and Texas that have previously sought such waivers, this formal guidance clears a path for implementation. States now have a concrete framework to submit new or revised 1115 waiver applications. Prepare for potential eligibility and documentation shifts if your state adopts these rules, affecting patient coverage verification workflows.

A new analysis details the financial impact of prescription drug prior authorization, breaking down the administrative costs borne by pharmacies and physician offices. The report provides concrete numbers on staff time and overhead associated with managing PA requests for specialty and brand-name medications. While payer reform efforts continue, this data reinforces the operational drag that prior authorization imposes on practice revenue cycles. It offers quantitative backing for practices negotiating service contracts or appealing to payers about the burden of their PA protocols.

Eli Lilly issued a direct warning to hospitals participating in the federal 340B drug discount program: submit required claims data within the next five days or lose access to discounts on its products. This enforcement action stems from Lilly's policy, implemented earlier this year, requiring 340B entities to provide detailed data on how discounted drugs are dispensed. Hospitals that fail to comply by the deadline risk a significant increase in drug acquisition costs. This move intensifies the ongoing conflict between drug manufacturers and 340B providers over program transparency. Affected hospital pharmacies and affiliated clinics must confirm their data submission status immediately to avoid financial disruption.