Thursday, July 2, 2026

Aetna has deployed a proprietary patient severity scoring methodology that deviates from the standard CMS-HCC risk adjustment model used by Medicare and most other payers. This non-standard policy creates significant reimbursement risk for providers, as claims coded under traditional models may not align with Aetna’s internal calculations, potentially leading to underpayments. Hospitals and health systems with substantial Aetna commercial contracts must audit their current severity documentation and coding processes against Aetna’s new guidelines immediately to identify and mitigate revenue gaps.

Montana has initiated its implementation of Medicaid work requirements for expansion enrollees. Able-bodied adults aged 19-64 must now document 80 hours per month of qualifying activities, including employment, education, or community service, to maintain coverage. This follows the Trump administration's final rule on Medicaid community engagement. Montana joins several other states enforcing similar requirements. Providers should anticipate potential coverage disruptions and eligibility verification challenges for affected patients. Check your state's Medicaid portal for specific documentation requirements and begin screening expansion population patients for potential compliance issues.

CMS is seeking expanded authority to more swiftly revoke the Medicare billing privileges of providers deemed 'problematic' due to prior fraudulent conduct, improper payment patterns, or quality-of-care concerns. The proposal, part of a broader anti-fraud push, aims to tighten enrollment safeguards and accelerate the recovery of improper payments. This signals a more aggressive posture from program integrity contractors and a lower threshold for administrative action. Monitor the comment period on the proposed rule CMS-1811-P for final details on how 'problematic' will be defined and the specific enforcement triggers.

CMS has published its proposed home health payment rule for 2027, which includes new provisions to tighten Medicare enrollment standards. The agency seeks expanded authority to deny or revoke provider enrollment based on potential fraud risk, including past relationships with problematic suppliers and patterns of abusive billing. This initiative, which includes mechanisms to more easily expel noncompliant providers and recover improper payments, represents a significant policy shift toward preemptive enforcement. The proposed rule is now open for public comment before finalization. Monitor the final CMS-2027-HH rule for the effective date of these new enrollment safeguards.

Substrate AI has launched a new automated eligibility verification tool designed to reduce claim denials caused by front-end administrative errors. The agent integrates with practice management systems to pre-validate patient coverage, benefits, and authorization requirements in real-time before service delivery. This reflects the ongoing shift in the RCM vendor landscape toward AI-driven automation to address the persistent and costly problem of denials rooted in registration and eligibility mistakes, which account for a significant portion of avoidable write-offs.