Thursday, August 27, 2026

Monogram Health, a kidney disease care provider, will pay $2.4 million to settle allegations that it submitted inaccurate risk-adjustment data to Medicare Advantage plans from 2019 through 2022. The Department of Justice investigation focused on upcoding, specifically the submission of diagnosis codes that were not supported by patient medical records. This settlement is part of a broader, multi-year enforcement push by federal agencies against risk-adjustment fraud in the MA program. The settlement requires Monogram to adhere to a five-year Corporate Integrity Agreement with HHS-OIG. Risk adjustment documentation for MA patients is now under intense scrutiny. Practices with MA contracts should review their own documentation and coding audit protocols for hierarchical condition categories (HCCs) immediately.

Work reporting requirements for Medicaid enrollees are now in effect in more than 40 states, with implementation deadlines hitting through the end of 2026. Henrico County, Virginia, expects over 20,000 residents to be impacted, requiring documentation of employment, volunteer hours, or approved exemptions. This is a direct eligibility change that clinics must address at point-of-service. Practices in affected states must update front-desk workflows to verify Medicaid patient eligibility under the new rules; a standard eligibility check may no longer suffice. Confirm your state's specific requirements and deadlines through your state Medicaid agency's provider portal.

CMS has issued new guidance indicating a more rigorous review of claims for applied behavior analysis (ABA) and other autism services. The guidance highlights concerns over the medical necessity of intensive, long-term therapy regimens and calls for more robust documentation linking treatment plans to measurable functional outcomes. This move follows a 2025 OIG report that found significant vulnerabilities in Medicare and Medicaid payments for ABA services, including insufficient documentation and questionable billing patterns. Providers of autism and behavioral health services should anticipate increased prepayment reviews and potential post-payment audits. Monitor your local MAC bulletins for specific implementation details and prepare to strengthen clinical documentation that explicitly ties service frequency and duration to individualized patient goals.

An expert FAQ breaks down the operational timeline and scope of the federal prior authorization reform rule set to take effect January 1, 2027. The rule mandates that CMS-regulated plans (Medicare Advantage, Medicaid managed care, and qualified health plans on the federal exchange) implement a standardized electronic PA process. Key requirements include providing specific denial reasons, publicly reporting denial rates, and adhering to decision timelines (72 hours for urgent requests, seven days for standard). The FAQ notes that while the rule is a significant step, gaps remain; for example, it does not cover employer-sponsored plans or address the underlying clinical criteria used for denials. Billing teams should use the next 16 months to prepare: confirm your EHR/PM system's readiness for the new FAST electronic standards, review contracts with payers not covered by the rule, and train staff on the new appeal windows and documentation requirements.

Governor Spanberger of Virginia signed an executive order to use state funds to fill anticipated gaps in federal funding for Medicaid and SNAP. The move is a response to federal budget cuts and aims to prevent coverage loss for vulnerable populations. State-level actions to shore up safety net programs may become a trend as federal support shifts. Clinics in Virginia should monitor the state's Department of Medical Assistance Services for any changes to enrollment or reimbursement tied to this funding bridge. Other states facing similar federal cuts may follow, affecting local Medicaid dynamics.