Friday, August 28, 2026

The American Academy of Sleep Medicine is calling on providers to advocate for fair payment of the new unattended sleep testing codes (95800, 95801, 95806). The codes, which took effect in 2026, are still facing payer resistance and undervaluation. CMS's proposed 2027 Physician Fee Schedule does not adequately address the resource costs for home sleep apnea testing. The AASM urges sleep specialists and referring physicians to submit comments to CMS before the September 2026 deadline, citing specific data on equipment, interpretation time, and patient management. Payment for these services remains unstable.

The Villages Health, a practice owned by Humana, will pay $542 million to resolve allegations it submitted false claims to Medicare. The Department of Justice claims the Florida-based primary care group billed for evaluation and management services that were not medically necessary or not provided. The settlement targets alleged upcoding and improper documentation practices. This action signals ongoing DOJ scrutiny of corporate-owned medical groups and their billing patterns. It follows a recent $2.4M settlement with Monogram Health. Medicare Advantage plans face increasing enforcement.

CMS is now using the Medicare enrollment process as a program-integrity tool, according to a legal analysis published today. The agency's scrutiny has intensified, requiring more extensive documentation and verification during enrollment and revalidation. This shift makes the Provider Enrollment, Chain, and Ownership System (PECOS) a frontline defense against fraud. Practices can expect longer processing times and more frequent requests for additional information. The analysis advises clinics to audit their enrollment records now for accuracy and to prepare for heightened verification during their next revalidation cycle.

XiFin research quantifies that mid-sized radiology practices lose an average of $2.6 million annually to billing gaps and inefficiencies in ancillary revenue cycles. The study identifies undercoding, missed charges for contrast administration, and poor denials management as primary drivers. The revenue leakage occurs across the technical and professional components. This figure represents recoverable revenue if practices implement tighter charge capture and proactive denial appeals workflows. The data suggests a systematic audit of coding and billing operations, especially for advanced imaging, could yield significant recoupment.

California legislators have introduced a bill aimed at lowering the cost of GLP-1 weight-loss drugs like Ozempic. The proposal seeks to leverage state purchasing power or impose pricing controls to increase affordability and access. With list prices exceeding $1,000 per month, patient access has been limited primarily to those with generous commercial coverage, while many Medicaid plans restrict or exclude coverage. The bill reflects growing political pressure to address pharmaceutical costs for chronic conditions, though specific mechanisms and fiscal impacts remain undefined. Monitor the bill's progress through committee hearings this fall; if enacted, it could create a state-level purchasing model that influences formulary decisions for both Medi-Cal and private plans operating in California.