Friday, September 11, 2026

Federal regulators have revoked Medicare billing privileges for 11 medical equipment suppliers. The CMS action was taken after audits found the firms submitted claims for beneficiaries who had already died. This is part of an ongoing enforcement wave focused on DME and supply fraud, following a series of similar suspensions earlier in the year. The suppliers are now barred from the Medicare program. Verify the billing credentials of any DME vendor your practice uses and cross-check any outside orders against your own patient records to prevent associated claim rejections.

Data shows Medicare Advantage plans issued 4.1 million prior authorization or payment denials in 2024. Of those, 80% were never appealed by patients or providers. For the 20% that were appealed, insurers reversed their decision four out of five times. The high reversal rate signals that a significant portion of initial denials may not be clinically justified. This trend places a greater operational burden on practices to track and appeal denials. Prioritize establishing a formal process for reviewing and appealing MA denials, as the success rate suggests it is a financially necessary step.

CMS finalized cutpoints for the 2027 Medicare Advantage Star Ratings, making roughly half of the performance measure thresholds more difficult for plans to achieve. The change particularly impacts measures related to managing chronic conditions and customer experience. Plans falling below certain star ratings face financial penalties and enrollment restrictions. This move is part of CMS's ongoing effort to tighten program standards. Monitor your Medicare Advantage plan partners' star ratings in October 2026 previews, as lower scores can signal network changes or benefit reductions for the 2027 plan year.

CMS has opened a formal inquiry into the American Medical Association's control over the Current Procedural Terminology code set. The agency questions whether the AMA's proprietary ownership of CPT creates a monopoly that stifles innovation and increases costs for the healthcare system. The public comment period on this issue closes September 14, 2026. While any potential change to the code-setting process is years away, the scrutiny highlights growing federal discomfort with industry-controlled billing standards. This is a structural shift to monitor, as it could eventually alter how new codes are created and valued.

Aetna agreed to pay $117.7 million to resolve allegations it submitted false claims to the Medicare Advantage program, according to a Justice Department settlement. The investigation centered on risk-adjustment coding practices where the insurer was accused of submitting unsupported diagnosis codes to increase payments. This settlement follows similar enforcement actions against other major Medicare Advantage plans, signaling continued federal scrutiny of risk-adjustment practices in the program. The case underscores the financial and compliance risks for insurers in Medicare Advantage and reinforces the importance of accurate coding and documentation.