Tuesday, June 30, 2026

Multiple reports confirm Medicare Advantage plans are quietly dropping physicians and hospitals from their networks mid-year, leaving patients locked into their plan until the next open enrollment period in January 2027. This practice, which disrupts established patient-provider relationships, is a growing concern for independent practices that rely on MA patients. Billing managers should proactively communicate with high-MA-volume patients now to confirm their 2026 network status and prepare for potential patient transfers or out-of-network billing discussions if contracts have been terminated.

MedLearn Publishing released a preview of Inpatient Prospective Payment System (IPPS) changes for FY27, with a focus on major and complicating condition (MCC/CC) status updates. The preview indicates CMS may adjust DRG weights for certain diagnoses that shift between MCC and CC categories. This directly impacts hospital reimbursement for Medicare inpatient stays. Billing teams should monitor the official FY27 IPPS final rule when it publishes for specific codes affected. Review the MedLearn preview to understand the potential DRG impact on your high-volume inpatient diagnoses. The official rule typically lands in late July or early August.

The U.S. House Energy and Commerce health subcommittee advanced legislation to curb prior authorization requirements in Medicare Advantage and other federal health programs. The bill, supported by the American Medical Association and radiology groups, includes provisions to streamline approvals and require more transparency from plans. While still early in the legislative process, the subcommittee vote is a concrete step forward for a policy that would reduce administrative burden. Monitor the bill's progress (HR number not specified in signal) as it moves to full committee. This signals building bipartisan momentum to address a top provider complaint.

A coalition of 26 Democratic-led states sued the Trump administration on June 29, challenging the recently finalized Medicaid work requirement rule. The lawsuit argues the rule's 'frail' exemption criteria unlawfully restrict coverage and conflict with the program's purpose of providing medical care. This legal action follows the rule's publication in the Federal Register, which opened the door for state-level implementation and enforcement. Monitor the docket number when assigned, as this litigation will determine whether states can proceed with implementing Medicaid community engagement mandates that could affect patient coverage and practice volume.

The CMS awarded Serco a $109 million contract to support the Comprehensive Error Rate Testing (CERT) program, extending the company's role in Medicare program integrity. The CERT program measures improper payments in traditional Medicare by sampling claims. Contractor shifts can sometimes influence audit focus areas or review patterns. This contract renewal signals continued, systematic post-payment review activity by CMS. Expect no immediate change to audit volume or methodology, but know the CERT program infrastructure remains a funded priority.