Friday, June 12, 2026

The HHS Office of Inspector General reported a pattern of inappropriate prior authorization denials for long-term and rehab care in Medicare Advantage. The report, which analyzed 2024 data, found plans frequently denied stays at long-term acute care hospitals and inpatient rehabilitation facilities, often reversing those denials on appeal. This signals increased payer scrutiny on post-acute care authorizations. Watch for increased denial rates on claims for CPT codes 99304-99310 and 99315-99316, and corresponding DRGs. Prepare to appeal with detailed clinical documentation for any MA patient needing skilled nursing or rehab placement. The OIG has urged CMS to increase oversight of MA denials for these services.

Twelve physician societies, including the American College of Radiology and the Society of Interventional Radiology, endorsed the Strengthening Medicare for Patients and Providers Act. The bill aims to address payment disparities between hospital outpatient departments and independent physician offices for the same interventional radiology services. This follows years of advocacy highlighting how site-neutral payment policies have created a financial disincentive for providing complex care in office settings. The legislation proposes to recalibrate the Medicare Physician Fee Schedule to better reflect the resources required for office-based interventional procedures. Monitor the bill's progress; if passed, it could increase reimbursement for office-based angiography, embolization, and biopsy services starting in 2027.

The HHS Office of Inspector General found Medicare Advantage plans frequently deny prior authorization requests for post‑acute care in skilled nursing facilities and inpatient rehabilitation hospitals. The OIG identified a pattern where denials often lack a sufficient clinical rationale or do not adhere to Medicare coverage criteria. While some denials are reversed on appeal, the process delays necessary care and burdens provider staff. This report signals intensified federal scrutiny of MA plan utilization management. Track the MA plan audit activity for your region; prepare for possible CMS enforcement actions around coverage determinations for SNF and IRF admissions.

Several large U.S. employers are preparing to exclude GLP-1 agonists for weight loss from their 2027 health plan formularies, citing unsustainable cost growth as usage surges. This follows Cigna’s recent move to drop coverage for its own employees. The shift could push thousands of patients to seek coverage through medical necessity appeals or pay out‑of‑pocket, creating administrative friction at practices that prescribe these drugs. Monitor your major commercial payer contracts for 2027 formulary updates; prepare your prior‑auth teams for potential increase in appeals for patients who meet strict medical criteria for obesity with comorbidities.

The U.S. Court of Appeals for the Fifth Circuit held that a mere difference of opinion on medical coding, without evidence of deliberate ignorance or reckless disregard, does not establish the scienter required for False Claims Act liability. The case involved a dispute over the appropriate billing level for evaluation and management services. The court distinguished between honest coding disagreements and fraudulent intent, reinforcing that good-faith compliance efforts matter. This ruling provides legal clarity for practices navigating ambiguous coding guidelines, particularly around E/M level selection and modifier usage. It does not change compliance obligations but underscores the importance of documented coding policies and ongoing education to demonstrate good faith.