Monday, June 22, 2026

CMS's WISeR model pilot, which uses artificial intelligence to expedite prior authorizations for certain procedures, is experiencing significant operational hurdles. Reports from participants indicate delays, processing errors, and unclear communication channels. The pilot was designed to reduce administrative burden, but early data shows it is struggling to meet that goal. CMS has not issued an official statement on the reported issues or a timeline for fixes. Billing teams in participating regions should monitor their WISeR submissions closely for denials or delays and escalate any issues immediately through the designated support lines. The House Appropriations Committee previously voted to block this pilot in June 2026, and these operational problems could fuel further congressional scrutiny.

An analysis of Medicare Advantage claims data has identified the five service categories most frequently denied by private MA plans. The list includes post-acute skilled nursing facility stays, inpatient rehabilitation, certain durable medical equipment, home health services following hospitalization, and advanced imaging for non-emergent conditions. Denial rates for these services are markedly higher than the MA plan average, often due to stringent medical necessity criteria or prior authorization requirements that exceed traditional Medicare standards. For practices with a high volume of MA patients, this requires a tactical shift: strengthen clinical documentation for these five service lines, initiate pre-service reviews for any elective imaging or DME, and prepare appeals packets in advance. The OIG has been actively investigating MA denial patterns, making payer behavior in these areas a compliance focal point.

The HHS Office of the Secretary published a correction to the 340B Rebate Model Pilot Program's information collection request. The notice fixes a technical error in the application form and implementation process described in a previous Federal Register document. This is a procedural correction for the ongoing pilot, which tests an alternative rebate model for certain drugs. Practices participating in the 340B program should confirm their application materials reflect the corrected information. The underlying pilot structure and drug pricing model remain unchanged.

Two Pennsylvania brothers have been convicted on racketeering conspiracy and other charges for orchestrating a $32 million Medicaid fraud scheme. The case, highlighted in a recent roundup of healthcare news, involved kickbacks and billing for medically unnecessary services. The potential 400-year combined prison sentence underscores the severe penalties for systemic fraud involving government healthcare programs. This follows other recent high-profile enforcement actions, including the $117.7 million Medicare Advantage settlement with Aetna finalized on June 15, 2026. The case reinforces the ongoing focus on anti-kickback and false claims enforcement by state and federal authorities.