Tuesday, September 1, 2026

CMS issued a formal notice urging providers to audit their billing for continuous glucose monitors (CGMs). The agency identified $278.5 million in improper Medicare payments related to CGM claims, signaling a clear audit target for program integrity units. The notice calls for a review of documentation supporting medical necessity, frequency of monitoring, and correct coding for supplies and professional services. Practices with CGM patients should pull a sample of claims from the last 12 months to verify documentation aligns with LCD requirements and that billing for supplies matches the monitor's prescribed use. Update staff on proper documentation now to prevent recoupments.

Billing consultancy Inga Ellzey is advising dermatology practices to perform a mid-year review of their revenue cycle performance before year-end closes. The firm highlights common leaks in derm billing, including improper use of modifier 25 with E/M services, incorrect coding for surgical procedures with biopsies, and denials for phototherapy and biologic drug administration. With payer policy updates and potential Medicare cuts on the horizon, the recommendation is to run key performance indicator reports now for A/R days, denial rates by payer and by reason, and clean claim rates. Identify your top three denial drivers and implement a corrective workflow by October to protect Q4 collections.

Revenue cycle management giant R1 RCM announced its acquisition of Humata Health, a company specializing in AI-driven prior authorization automation and payer-provider collaboration tools. The deal aims to integrate Humata's Phare OS platform into R1's suite, promising to reduce manual PA work for providers. This consolidation highlights the ongoing push by large RCM vendors to own the entire claims lifecycle with proprietary technology. Monitor R1's product roadmap for the integrated platform's launch and pricing; it may become a factor in future RCM vendor selection for practices struggling with PA backlogs.

Florida Attorney General Ashley Moody filed a state antitrust lawsuit against pharmacy benefit managers Express Scripts and Prime Therapeutics, alleging they conspired to fix prices and allocate markets for PBM services. The suit claims the companies’ coordination suppressed competition and inflated costs for Florida’s Medicaid managed‑care program and commercial plans. The action follows similar state‑level probes into PBM consolidation and adds momentum to federal efforts to regulate PBM spread‑pricing and rebate practices. Monitor the docket for interim rulings that could reshape PBM‑provider contracting in 2027.

Employer health plan sponsors report that GLP‑1 agonist drugs for obesity and diabetes are the single largest cost driver heading into 2027 benefit design. With per‑patient annual costs exceeding $10,000, more companies are imposing strict prior‑authorization criteria, shifting drugs to higher formulary tiers, or dropping coverage altogether, a move that shifts financial risk to patients and increases collection risk for practices. This employer‑led retrenchment contrasts with CMS’s new Medicare discount program, creating a fractured coverage landscape. Expect intensified payer‑employer negotiations this fall that will dictate 2027 formularies and patient access.