September 3, 2026
Medicare Part D plans made millions in payments for drugs that were ineligible under the program, according to a new federal audit.
This article was originally published on Fierce Healthcare.
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September 3, 2026
Medicare Part D plans made millions in payments for drugs that were ineligible under the program, according to a new federal audit.
This article was originally published on Fierce Healthcare.
Author: Veronica Richardson, MHA, RHIA, CHPS, CHC, Senior Compliance Consultant | September 2, 2026
Across the healthcare industry, the use of artificial intelligence (AI) has been growing exponentially. It’s changing the way medical records get reviewed, the way claims get scrutinized, and even the way clinical documentation gets written in the first place.
Payers, regulators, and provider organizations alike have begun leaning heavily on artificial intelligence, not as some futuristic concept, but as a working tool, already embedded in day-to-day operations. Many of our colleagues have discussed the surging impact this has had for regulatory oversight. On the data side, AI is being used to comb through massive volumes of claims and clinical data, flagging billing pattern outliers and quickly identifying deviations in a provider’s own practices, not just utilization that stands out from a peer group. This level of data analysis and auditing is at a scale human teams simply could not match working alone. What used to take analysts weeks of manual chart reviews and spreadsheet cross-referencing can now happen in a fraction of the time.
AI isn’t just analyzing data anymore, it’s stepping directly into the documentation process. In hospitals and behavioral health settings, AI‑powered tools are now acting as clinical scribes, listening to encounters and producing draft notes in real time. Others work behind the scenes as documentation improvement partners, scanning a finished note and flagging spots where more clinical detail or specificity could strengthen it.
The appeal is obvious. Provider burden, especially the late‑night “pajama time” clinicians spend finishing notes, remains one of healthcare’s biggest pain points. Tools that shave even a little off that workload feel like a win. And when those same tools help nudge documentation toward more complete, clinically grounded narratives, there’s hope that they also support something bigger: documentation that meets medical necessity standards. Given that medical necessity drives most reimbursement decisions and fuels most audit findings, that’s no small promise.
But there’s a cautionary thread running through all of this. As AI becomes more embedded in documentation workflows, organizations can’t afford to treat its output as plug‑and‑play. Drafts generated by AI still require solid clinical review — not just for accuracy, but to ensure the record reflects the provider’s actual clinical judgment. Without that oversight, the convenience of AI‑assisted documentation can quickly become a compliance risk rather than a relief.
So, on the surface, this looks like a win on two fronts — stronger documentation upstream, and smarter auditing downstream. Efficiency for compliance teams. Relief for clinicians. Better-supported claims.
However, healthcare compliance professionals will tell you this is where the real conversation begins, efficiency and volume are only part of the picture. As these tools move beyond simple data mining and start making judgment calls about clinical content itself, a new and more complicated set of questions emerges. Who’s checking the AI’s work? How much should organizations trust a finding that was generated without a human ever laying eyes on the chart? And what happens when the technology’s speed outpaces an organization’s ability to respond to what it’s uncovering?
A growing number of AI solutions on the market aren’t just analyzing claims data anymore. They’re going further, reading the documentation narrative itself, evaluating clinical appropriateness, assessing medical necessity, and checking whether a note meets documentation standards well enough to be considered complete and compliant. In effect, some of these tools are positioning themselves to take on work that has traditionally belonged to trained compliance auditors and quality assurance reviewers.
That’s a significant leap and an extremely appealing sale. And it’s why healthcare leaders are being urged to bring a discerning eye to these solutions rather than treating them as a plug-and-play replacement for human expertise. Because, like any AI-generated content, these findings can be wrong. That’s not a hypothetical caveat — it’s a documented reality of how these systems work. And it’s why the phrase you hear over and over in this space is “human in the loop.”
That phrase carries two distinct responsibilities. First, human auditing professionals need to be reviewing the findings AI tools produce — checking that those findings actually align with industry standards, applicable regulations, and the internal policies of the specific practice being reviewed. An AI model trained on general patterns doesn’t automatically know the nuances of one organization’s policy manual, or a particular payer’s contractual requirements.
Second — and this is a point worth sitting with — the efficiency of AI creates a genuinely attractive alternative to a traditional audit team reviewing a modest sample of progress notes. However, turning an AI solution loose to audit larger samples doesn’t just mean more coverage. It can mean more risk. There’s a saying in compliance circles that captures this perfectly: If you look, you find. And if you find, you must treat! Every finding an AI surfaces create an obligation. More findings, faster, means more obligations landing on an organization’s desk than it may be prepared to handle.
That risk multiplies with the newest capability entering the market — auto-feed functionality, where documentation and data flow into the AI analysis tool automatically, and results are produced essentially in real time. That sounds efficient: “Set it and forget it.” But consider the practical questions it raises. What happens with that data once it’s generated? How quickly can quality teams address clinical concerns highlighted in a chart review? How expediently can compliance professionals respond to findings — including potential overpayments — that the AI is identifying rapidly, and often continuously, on the organization’s behalf? At what point will an organization be searching for an AI agent to audit the AI auditing tool?
Organizations adopting these tools may find themselves sitting on a wealth of information they are simply not equipped to act on, or worse yet, may be playing defense against their own internally driven audit findings from a system that misses the mark. And in healthcare compliance, an unaddressed finding doesn’t just sit quietly, it becomes exposure. Under scrutiny, a backlog of unresolved audit findings makes it nearly impossible to argue that the organization “didn’t know” or “could not have known.”
So what’s the path forward? Industry voices are converging on a consistent answer: start small. Trust, but verify. Strategically select samples of data and documentation for review rather than defaulting to full-scale, automated audits from day one. AI is not leaving healthcare auditing anytime soon. The question every organization now must answer is whether their people, processes, and risk management resources can keep pace with what the technology can find.
This article was originally published on RACmonitor.
September 2, 2026
Thyme Care landed a series E financing round of more than $125 million backed by strategic payers and providers as it aims to expand beyond cancer care navigation.
This article was originally published on Fierce Healthcare.
September 1, 2026
Public comments for the latest OPPS proposed rule saw several major hospital groups all but threatening a court showdown over CMS’ planned policy changes.
This article was originally published on Fierce Healthcare.
September 1, 2026
UnitedHealthcare said earlier this year that it was aiming to eliminate 30% of prior authorization requirements by the end of 2026.
This article was originally published on Fierce Healthcare.
August 28, 2026
Maryland has filed a lawsuit against UnitedHealth Group, alleging that its Optum unit defrauded the state’s Medicaid program by providing a faulty computer system.
This article was originally published on Fierce Healthcare.
Author: Stephanie Armour | August 28, 2026
In the thick of his competitive reelection race in Michigan, Republican Rep. Tom Barrett joined Health and Human Services Secretary Robert F. Kennedy Jr. at a sprawling 400-acre apple orchard, farm, and winery. They touted Trump administration efforts to improve the American diet, including the removal of some artificial dyes from processed foods.
“We had a great discussion about healthy options for all Americans and taking back control of our healthcare,” Barrett said in a June Instagram post, after sampling the farm’s apple cider.
Like the focus on artificial dyes, however, many of the administration’s highest-profile health initiatives rely on voluntary agreements. The goals, such as lower drug prices and nutrition classes for doctors, have widespread appeal, cutting across party lines and economic divisions.
But the administration-industry deals lack the enforcement teeth of more traditional federal regulation. Their details are vague, and minimal oversight makes it hard to monitor progress. In some cases, the administration has claimed victories that have yet to materialize.
Republicans consider the dealmaking a winning strategy. It fits with the party’s anti-regulatory stance, they say, and enables the administration to quickly forge agreements President Donald Trump and his allies can tout as accomplishments. In the run-up to the midterm elections, some, like Barrett, hope to woo voters by trumpeting the Trump administration’s efforts to shape health policy.
The practice also raises questions. Though the deals are announced with great fanfare — often during televised events on stages, with live audiences — there’s little documentation or follow-through, creating doubts about whether the administration’s health agenda will lead to lasting change or unravel once the political attention fades.
The distinction could prove important to voters as Republicans defend their health records in November’s midterm elections.
“These deals are often not transparent, so there’s no way for the public to judge how meaningful they are,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News.
Dealing With Dyes
The push to remove certain artificial dyes from food and drugs, for example, was a headline grabber. In April 2025, Kennedy strode onto an HHS stage to announce deals with food makers. He was flanked by young children and mothers holding placards reading “Make America Healthy Again.”
He and former FDA commissioner Marty Makary drew a standing ovation from an audience selected by Kennedy’s staff as they said companies had pledged to phase out all petroleum-based synthetic dyes from the nation’s food supply and medicines. They targeted nine synthetic dyes for removal.
Voters love the idea of stopping the use of such dyes. In a nationally representative March survey by Consumer Reports, 72% of adults said they were at least somewhat concerned about synthetic dyes, and two-thirds said companies should be required to phase them out.
A year after making the first announcement at HHS, Kennedy declared victory during a discussion at the Conservative Political Action Conference, an annual political event.
“We’ve gotten rid of the nine synthetic-based food dyes,” he said.
Not quite. At the initial HHS event, federal officials said companies would voluntarily stop using six specific synthetic dyes by the end of this year. (The administration has also revoked or proposed revoking authorization for two other synthetic food dyes.)
Later, the FDA on its website quietly changed the deadline to the end of 2027. So, most are still in use.
In fact, the FDA posted a list of 27 companies it said had made voluntary pledges as of December 2025 to remove six synthetic dyes from products such as Doritos and Kellogg’s Froot Loops. More than a year and a half later, seven food makers — fewer than 30% of those who bought in — had met their promised goals.
Many major food makers, such as the Coca-Cola Co. and Unilever, have made “no concrete commitments” to remove the synthetic dyes, according to Consumer Reports. In addition, no pharmaceutical companies have publicly said they have plans to remove dyes from drugs.
“It’s just all talk,” said Leslie Dach, who chairs Protect Our Care, a healthcare advocacy group that supports the Affordable Care Act. “They just govern for a day of publicity, and then it’s over. None of it happens. Yet the people don’t know because they have busy lives, so they think, ‘Just look at all these initiatives.’”
In fact, the administration loosened labeling requirements, allowing companies to say their products contain no artificial colors — as long as they don’t use petroleum-based dyes. Previously, food makers could not make that claim unless their products contained no added colors. Some food dyes made from natural ingredients can contain contaminants and may pose their own health risks, such as diabetes.
“The federal government hasn’t taken any regulatory action on food dyes, for the most part, since the beginning of this administration,” said Melanie Benesh, vice president for government affairs at the Environmental Working Group, an advocacy group.
HHS said the voluntary approach has yielded significant action, including commitments to remove synthetic dyes from products sold in schools for the 2026–27 school year.
“HHS and the FDA are moving forward with clear timelines and concrete industry commitments, with major changes expected in foods served in schools during the coming school year and across full product portfolios by the end of 2027,” HHS spokesperson Emily Hilliard said in an email.
At the same CPAC convention event, Kennedy said “the MCAT testing companies are going to put nutrition on the MCAT for the first time, so the students will actually want to do it.” MCAT refers to the Medical College Admission Test, an exam required for admission to medical schools.
Again, not quite.
The Association of American Medical Colleges administers the MCAT. Spokesperson Stuart Heiser said Kennedy misspoke and may have meant to refer to a test taken by students to be licensed as doctors.
An Insurance Deal Falls Short of Promises
Kennedy again took to the HHS stage in June 2025, this time with Centers for Medicare & Medicaid Services Administrator Mehmet Oz, to make what was billed as a game-changing announcement. Major insurers, they said, had agreed to reduce the volume of healthcare services subject to prior authorization, a practice widely used by the insurance industry that often requires patients or their medical teams to seek preapproval before undergoing treatment.
The administration said 80% of insurers pledged changes to preauthorization requirements for 80% of diseases and injuries by January 2026. The administration also promised “public dashboards” to track progress.
“It will happen very quickly,” Oz said at the event. “Necessary care will be delivered when it’s needed, in the right way.”
As of July, months past that January target date, health plans had reduced prior authorization for medical services by about 11%, according to AHIP, the insurer trade group. But no public dashboards have debuted to track the deal, and some insurers that signed the pledge last summer told KFF Health News this year that they will not implement all the promised reforms as outlined by AHIP.
Hilliard did not respond to questions about the pace of progress.
The American Medical Association, in a 2025 web-based survey, asked 1,000 practicing doctors whether they believed the voluntary pledges would make a meaningful difference. Only 1 in 3 said they believed they would.
Insurers made a similar promise in 2018, during the previous Trump administration. The next year, more than 80% of doctors said the number of prior authorization requests for drugs and medical services had been increasing, based on another AMA survey.
Meanwhile, the administration is testing an artificial intelligence-powered prior authorization system for Medicare, the federal health program for people 65 and older or with disabilities. In six states, Medicare beneficiaries must get preapproval for a few treatments that CMS considers to have little clinical benefit and to be susceptible to fraud or waste, including skin substitutes and knee arthroscopy for arthritis. The program began in January, the same deadline insurers had set for curtailing preauthorization delays.
Deals and Deregulation
The healthcare industry’s voluntary agreements appeal to voters who feel government regulation drives up costs and places unnecessary burdens on businesses, some supporters say.
“Secretary Kennedy is the antithesis of a public health industry that uses coercion over communication — and has demonstrated this by taking the time and effort to push voluntary initiatives over the typical approach of governmental mandates,” said David Mansdoerfer, a political consultant who was a political appointee at HHS in Trump’s first term.
But voluntary agreements with the health industry can prove ineffective. Former President Jimmy Carter in 1977 proposed a legislative plan to curb rising hospital costs. Hospitals fought back, and Congress rejected the proposal, instead favoring a voluntary approach desired by the industry. It ultimately failed once public attention faded.
One upside: Deals are fast. Enacting a federal regulation can take two to three years. And some health analysts say the tempo of the agreements advanced by Kennedy and Trump may help take voters’ attention off the Trump administration’s inability so far to produce a long-promised health plan.
Instead, Republicans can point to the array of accords reached with industry, including the administration’s voluntary arrangement with drugmakers to cut prices so they’re in line with lower amounts charged in peer countries. The White House calls it the “most-favored-nation” prescription drug pricing policy.
Seventeen companies, including Pfizer and AstraZeneca, announced agreements with the administration to lower prices for Medicaid enrollees and cash-paying consumers using TrumpRx, a narrow, government-run consumer platform.
Many details remain unknown, but the lower prices apply only to new drugs and existing drugs available through Medicaid. And prices at TrumpRx aren’t as low as out-of-pocket prices for most consumers with insurance. But the voluntary deals appeal to an industry that has railed against mandatory approaches drugmakers deride as harmful price controls.
“Each company makes its own decisions about how it prices medicines, and our industry is committed to working with the Trump administration to ensure Americans have access to affordable medicines,” said Chanse Jones, a spokesperson for PhRMA, a pharmaceutical industry trade group.
Policies that lead to reductions in drug prices typically worry investors because profits also can drop. But rather than seeing their stock prices fall after the agreements were announced, the drugmakers saw largely positive market reactions.
Analysts say that’s partly because the deals are narrow in scope, largely exist only in principle, and don’t apply to existing drugs used by the more than 200 million Americans with commercial or private health insurance.
The Trump administration, however, is claiming success.
“The most-favored-nation agreements on drug prices that we just did are delivering the largest drug price cuts in history,” Trump said in June at a Mack Trucks plant in Pennsylvania. “That alone should win us the midterms.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
This article was originally published on KFF Health News.
August 27, 2026
The Villages Health System has agreed to a $541.5 million settlement to resolve allegations that it submitted false diagnosis codes to secure higher payouts in Medicare Advantage.
This article was originally published on Fierce Healthcare.
August 27, 2026
In the latest in a string of setbacks in biopharma’s efforts to fight Medicare drug price negotiations, a lawsuit from the industry’s top lobbying group has been rejected at the appeals level.
This article was originally published on Fierce Healthcare.
Author: David M. Glaser, Esq. | August 26, 2026
A recent decision from the 6th Circuit Court of Appeals produced both some excellent and some depressing news.
Let’s start with the positive.
Over the years, we’ve explained the protections offered by the “without fault” provision of the Social Security Act. Both Sections 1870 and 1879 of the Act have provisions requiring the waiver of an overpayment, with 1879 applying if the organization providing a service reasonably believes that the service will be covered. Well, in one case, In Home Health, LLC v. Kennedy, the 6th Circuit ruled on July 27 that “if a provider reasonably – albeit incorrectly – interpreted the Medicare notices and standards as covering a patient’s claim, then the safe harbor saves them from liability.” While I have generally used the term “safe harbor” only to refer to provisions in the federal antikickback regulations, not 1879, I understand why the Court likes the phrase.
The statement that a reasonable but incorrect belief in coverage requires waiver of an overpayment is remarkably helpful. The Court of Appeals is saying that even if a healthcare organization is wrong when it concludes that a particular service is covered, if its thought process was reasonable, the government isn’t allowed to recoup money.
The clarity of that sentence will be very useful in appeals, and a reminder that before making any refund, consider whether you are without fault under 1870 – and whether you had reason to believe that services were necessary under 1879.
But the decision isn’t all good news.
The case involves an appeal by a hospice. In an audit, the Medicare Administrative Contractor (MAC) concluded that many of the patients did not satisfy the definition of “terminal illness” found in a local coverage determination (LCD). As we’ve discussed before, I don’t think LCDs are generally binding. It doesn’t appear that the hospice challenged the validity of the LCD, so this decision doesn’t really address that important question.
But the Court did focus on the standard of review when an appeals court is looking at an administrative law judge’s (ALJ’s) decision. If you’re ever in a situation in which you want to appeal an ALJ’s decision in district court, you’ll want to fully understand just how limited that review will be. The court will give considerable deference to the ALJ.
As the court explains (with a variety of citations and internal quotes omitted), “we must affirm the underlying decision unless we determine that substantial evidence did not support it. Substantial evidence ‘falls somewhere between more than a scintilla but less than a preponderance.’ It ‘does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.’ Reviewing for substantial evidence precludes us from reweighing conflicting evidence, making credibility determinations, or substituting our judgment for the ALJ’s reasoned determination.”
Despite all the excitement about how Loper Bright would limit deference to the government, a lot of deference remains. When there is any evidence supporting the ALJ, the court will yield to it.
Prevailing in an appeal is rarely a cakewalk.
This article was originally published on RACmonitor.