Tuesday, June 23, 2026

A new alert details recently updated requirements for returning identified Medicare overpayments. The rule governs the process, timing, and reporting obligations when a practice discovers it has received funds to which it is not entitled. Failure to comply can trigger False Claims Act liability. Billing teams must ensure their compliance officers and RCM staff are aware of the updated protocol. Review internal processes for identifying, quantifying, and reporting overpayments to avoid significant penalties.

CMS data shows suppliers of durable medical equipment, prosthetics, orthotics, and supplies generate the highest improper payment error rates in Medicare. The focus on DMEPOS claims signals ongoing scrutiny of documentation, medical necessity, and coding. This trend suggests practices handling DMEPOS billing should prioritize internal audits of these claims and ensure thorough supporting documentation is captured and maintained. Expect continued MAC and RAC audit activity in this area.

Major cardiology societies are formally opposing the planned expansion of the CMS WISeR AI prior authorization pilot model, which applies to certain cardiovascular procedures. Citing concerns over accuracy, transparency, and patient access, the groups are urging CMS to halt the expansion beyond the current pilot phase. This formal pushback adds to reports of a 'rocky start' for the program. Cardiology practices should monitor CMS communications and specialty society alerts for any changes to the model's scope or implementation timeline.

CMS is tightening oversight of a $50 billion fund for rural hospitals and clinics established by recent legislation. The agency clarified that states must use the money for qualifying investments like facility improvements or telehealth expansion; funds spent on non-qualified operational costs will be subject to clawback. This move signals a shift from a flexible grant program to a performance-based model. Rural providers that received or plan to apply for these funds must audit their planned use against the final rule's requirements to avoid future repayment demands. Monitor CMS guidance on qualifying expenditures to ensure compliance and protect funding.

A new report finds combined Medicaid and ACA marketplace enrollment has dropped by more than 5 million people, driven by the expiration of the pandemic-era continuous coverage provision and the implementation of new work requirements under the One Big Beautiful Bill. Analysts at the National Health Law Program are urging states to use their Medicaid Automated Eligibility Systems to closely track how OBBBA work requirements are being implemented, warning of procedural denials and coverage losses unrelated to actual employment status. For practices, this means more patients may present as uninsured or with disrupted coverage. Monitor your state's Medicaid agency reports on disenrollment reasons and prepare front-office staff for increased eligibility verification complexity.