Friday, September 18, 2026

The HHS Office of Inspector General released audit findings alleging Humana and UnitedHealthcare Medicare Advantage plans submitted risk-adjusted diagnosis codes that lacked sufficient documentation, resulting in overpayments. The findings signal a tightening enforcement focus on chart documentation for risk-adjustment factor (RAF) coding. This raises the risk of retrospective payment recoupments for plans, which could translate to increased audit scrutiny for providers whose documentation supports those codes. Monitor plan communications and prepare for potential chart requests to substantiate RAF submissions.

Aetna announced a new process to bundle prior authorizations for multi-step cancer treatment regimens, aiming to reduce administrative burden. This means a single approval may cover an entire course of chemotherapy or radiation rather than requiring separate authorizations for each phase or cycle. Oncology practices billing Aetna should confirm the new workflow details through the payer's provider portal and adjust internal tracking to align with the bundled approval structure. Verify that claims submitted under a bundled auth reference the correct approval ID to avoid denials.

CMS published a notice for the continued approval of DNV Healthcare USA Inc.'s hospital accreditation program. DNV is one of several accrediting organizations whose stamp allows hospitals to participate in Medicare and Medicaid. The notice opens a public comment period for stakeholders to provide feedback on DNV's performance. For hospitals accredited by DNV, this is a routine procedural step, not an indication of immediate change. The outcome reaffirms the accreditation pathway for billing Medicare.

Reps. Onder and Landsman introduced the bipartisan Medicare Advantage Care Bill, which would mandate Medicare Advantage plans respond to prior authorization requests within 72 hours for non-emergent services. The bill aims to address widespread provider complaints about multi-week delays that stall care, particularly for specialty treatments and durable medical equipment. While similar proposals have stalled in past sessions, this bill emerges amid growing scrutiny of MA plan administrative burdens and patient access. If enacted, it would significantly accelerate the authorization workflow for practices, reducing claim holds and patient rescheduling. Track H.R. progress; the 72-hour standard could become a benchmark for commercial payers if it gains traction in MA.