Thursday, June 18, 2026

HHS OIG has published new industry-specific guidance for auditing Medicare Advantage plans. The guidance outlines how OIG will assess plan compliance, targeting areas like prior authorization denials, coding accuracy, and network adequacy. This formalizes the agency's recent focus on high denial rates for post-acute and skilled nursing care. Monitor the CMS-2026-XXXX docket for formal rulemaking, as this guidance signals increased enforcement activity for 2027. Practices should prepare for more payer-initiated audits and potentially slower prior authorization responses as plans adjust to the new scrutiny.

Alabama Medicaid will require a prior referral for all Applied Behavior Analysis therapy claims related to autism spectrum disorder, effective July 1, 2026. The new rule mandates that a primary care physician or specialist must issue the referral before ABA services can be billed. Claims submitted without the documented referral after the go-live date will be denied. Providers must update their intake workflows for pediatric patients and verify the referral is in the patient's chart before initiating ABA services. Contact the Alabama Medicaid provider portal for the specific referral form and documentation requirements.

CMS issued a Request for Information seeking public comment on Pharmacy Benefit Manager compensation models and data collection practices. The agency is exploring how PBM rebates, fees, and formulary management affect drug costs for Medicare Part D and commercial plans. This is a preliminary step toward potential rulemaking that could change how PBMs operate and disclose their financial arrangements. The RFI does not impose new requirements but signals CMS's focus on pharmacy benefit transparency. The comment period will be announced in the Federal Register notice.

A new report identifies Kansas as the state with the most rural hospitals at immediate risk of closure. The analysis cites persistent low occupancy, high reliance on government payers, and staffing shortages. For independent practices, rural hospital closures mean longer travel for inpatient referrals, reduced local lab and imaging access, and increased patient burden. This trend underscores the fragile economics of rural healthcare delivery, where practice viability is tied to local hospital infrastructure. Billing teams should monitor local hospital financial statements and prepare contingency plans for patient referrals and care coordination if a closure is announced.