Friday, June 26, 2026

The federal government reprimanded a private company using artificial intelligence to review Medicare claims in Washington state for causing significant processing delays. The delays affected patient access to care and provider reimbursement. This action highlights ongoing operational risks as CMS and other payers expand pilot programs that outsource medical necessity reviews to third-party AI vendors. Billing teams in states with similar AI pilot programs should monitor claim processing times and prepare for potential appeals tied to algorithmic denials or delays. The specific contractor was not named in the report.

The Improving Seniors’ Timely Access to Care Act has cleared a key House committee markup, signaling bipartisan momentum for federal prior authorization reform. The bill, supported by major medical societies, aims to standardize and streamline PA processes in Medicare Advantage plans, including requirements for real-time decisions for routinely approved services and greater transparency on denial rates. While final passage is not guaranteed, the committee action increases pressure on private MA plans to preemptively adjust their PA protocols. Billing managers should track the bill's progress (H.R. 3173) as it moves toward a potential House floor vote later this summer.

Nevada has initiated a six-month, concentrated effort to investigate and prosecute Medicaid fraud, waste, and abuse. The state's Medicaid program integrity unit is focusing this sweep on provider billing patterns, with an emphasis on high-cost services like behavioral health, durable medical equipment, and personal care services. Nevada-based practices and those billing Nevada Medicaid should conduct an internal audit of their Medicaid claims for the last 12 months, ensuring coding and documentation fully support billed services. Expect increased audit activity and prepayment reviews through the end of 2026. Proactively address any discrepancies to avoid penalties or suspension.

Senator Bill Cassidy (R-LA) proposed legislation to impose new restrictions on the 340B program, including mandatory rebates from covered entities to the federal government for certain drugs and limitations on the use of contract pharmacies. The bill also seeks to tighten eligibility and increase transparency. This represents the most concrete Republican-led effort to reform the program, which has faced bipartisan scrutiny over its growth. The proposal will be debated in the Senate Health, Education, Labor, and Pensions Committee; track the bill's docket number for hearing dates and potential amendments.