backCMS Issues CY 2027 Physician Fee Schedule Proposed Rule
On July 14, 2026, CMS published the Calendar Year (CY) 2027 Medicare Physician Fee Schedule (PFS) Proposed Rule (CMS-1848-P). The proposed rule would, among other things, make changes to Medicare physician payment policies, practice expense methodology, evaluation and management (E/M) coding, remote monitoring requirements, global surgery payments, and the Medicare Shared Savings Program, among other areas. If finalized, the rule would take effect on January 1, 2027. Comments on the proposed rule are due by September 14, 2026.
Below is a summary of the key provisions of the proposed rule:
CY 2027 PFS Rate Setting and Conversion Factor: Beginning in CY 2026, CMS established two separate conversion factors under the PFS: one for qualifying alternative payment model (APM) participants (QPs) and one for non-QPs. For CY 2027, CMS proposes a conversion factor update of +0.75% for QPs and +0.25% for non-QPs. CMS also proposes an estimated +0.53% budget neutrality adjustment to account for proposed changes in work relative value units (RVUs). However, the Working Families Tax Cut (WFTC) legislation provided a one-year 2.50% PFS conversion factor increase for CY 2026 only, which expires for CY 2027. This effectively results in a 2.50% reduction in Medicare payment under the PFS compared to CY 2026 levels. Consequently, the proposed CY 2027 qualifying APM conversion factor is $33.17, a decrease of $0.40 (or approximately 1.19%) from $33.57, and the proposed CY 2027 nonqualifying APM conversion factor is $32.84, a decrease of $0.56 (or approximately 1.68%) from $33.40.
Quality Payment Program: CMS proposes updates to the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) for CY 2027. Consistent with the Consolidated Appropriations Act, 2026, the APM Incentive Payment would be 3.1% for payment year 2028. The qualifying participant (QP) thresholds for the 2027 QP Performance Period would be 75% for payment amount and 50% for patient count. CMS also proposes to move the Electronic Prior Authorization measure from a required measure to a bonus measure for the CY 2027 performance period. In addition, CMS proposes to phase out traditional MIPS reporting and transition to MIPS Value Pathways (MVPs) as the sole reporting option for MIPS eligible clinicians not participating in the APM Performance Pathway (APP). Under this proposal, traditional MIPS reporting would be sunset beginning with the CY 2029 performance period/2031 MIPS payment year. CMS is proposing three new MVPs focused on diabetic disease, hypertension, and hospital-based care, which would bring the total MVP inventory to 30 and provide a reporting option for approximately 98% of specialties. The APM Incentive Payment has been extended multiple times by Congress, with varying percentages: 5% for payment years 2019 through 2024, 3.5% for payment year 2025, 1.88% for payment year 2026, and now 3.1% for payment year 2028 under the Consolidated Appropriations Act, 2026. No APM Incentive Payment is available for payment year 2027.
Medicare Shared Savings Program: CMS proposes multiple changes to the Medicare Shared Savings Program (MSSP). With respect to beneficiary assignment, CMS proposes to modify the claims-based assignment methodology to exclude from assignment calculations the allowed charges for primary care services billed through a non-ACO TIN by an ACO professional, which CMS states is intended to reduce vulnerabilities that could allow ACOs to avoid accountability for higher-cost beneficiaries. CMS also proposes to expand assignment eligibility criteria based on Medicare enrollment status, beginning with the performance year starting January 1, 2028, to increase the number of Medicare fee-for-service beneficiaries in accountable care relationships. Together, these assignment changes are estimated to reduce program spending by $2.3 billion over 10 years. CMS also proposes to increase the shared savings rate for Level E of the BASIC track from 50% to 60% for agreement periods beginning on or after January 1, 2027, and to reduce the maximum weight used in calculating the positive regional adjustment for lower-spending ACOs under the ENHANCED track from 50% to 35%. CMS further proposes to allow all Shared Savings Program ACOs to reduce or eliminate Part B cost sharing for eligible beneficiaries who do not have secondary insurance, subject to approval of an implementation plan and alignment with specified clinical goals. CMS proposes to discontinue the availability of the prepaid shared savings option. Additional proposals address benchmark calculations, Accountable Care Prospective Trend (ACPT) reform, advance investment payment methodology, and beneficiary notification requirements.
Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM): CMS proposes several changes to remote monitoring services. First, RTM services would be required to be furnished only to established patients. Practitioners reporting RPM or RTM would be required to furnish a separately reportable initiating visit. CMS proposes to only allow payment for RPM or RTM services when performed by clinical staff employed by the practice, and not when delivered by contractors or third-party companies. CMS also proposes updates to device valuation, noting that devices may now be available at reduced cost. Additionally, CMS is considering, and seeking comments on, bundling the RPM and RTM CPT codes and creating four new HCPCS G-Codes to describe remote monitoring services, which would reduce 17 existing codes to 4. CMS notes that this approach would address recommendations from recent OIG reports that it does not believe can be fully resolved with the current coding structure.
Practice Expense Methodology Reform: CMS proposes to phase out reliance on outdated specialty-specific practice expense per hour (PE/HR) data from 2007 or earlier. Specifically, CMS proposes to remove the Indirect Practice Cost Index (IPCI) from practice expense RVU calculations over a two-year transition period. To mitigate short-term volatility, CMS proposes a PE stabilization adjustment under which PE RVUs would not increase or decrease by more than 5% in any given year. CMS notes that this proposal is part of a multi-year effort to transition practice expense methodology toward more objective, routinely updated, and auditable cost data. CMS is also seeking comments on whether the site of service payment differential between facility and non-facility settings remains appropriate.
Rural Health Clinics and Federally Qualified Health Centers: CMS proposes to recognize diabetes self-management training (DSMT) and medical nutrition therapy (MNT) services as qualified preventive services paid at the all-inclusive rate in Rural Health Clinics (RHCs). CMS also proposes conforming regulatory changes so that mental health in-person visit requirements would not apply through December 31, 2027, consistent with the Consolidated Appropriations Act, 2026 (CAA, 2026). The CAA, 2026 also extended the authority for CMS to pay RHCs and FQHCs for non-behavioral health visits furnished via telecommunication technology through December 31, 2027.
Global Surgery Payment and Data Collection: CMS proposes to pause the data collection required by Section 523 of the Medicare Access and CHIP Reauthorization Act (MACRA). CMS indicates it has accumulated several years of data showing that post-operative visits during the global period are frequently not occurring, yet providers continue to be paid for them. CMS believes the current data collection requirements may be causing undue burden on practitioners. As part of this proposal, CMS is posting a public use file showing imputed RVUs for 10- and 90-day post-operative visits and is soliciting comments on potential revaluation strategies and expanding data collection approaches.
Chronic Disease Management and Behavioral Health: CMS proposes to establish separate coding and payment for shared medical appointments, which are group-based sessions for patients with common chronic conditions involving 2 to 10 patients. CMS also proposes to include smoking and tobacco cessation services, as well as Screening, Brief Intervention, and Referral to Treatment (SBIRT) services, in the final year of the transition for timed behavioral health codes, which would result in increased work RVUs for these services. Shared medical appointments would be limited to beneficiaries who have an existing clinical relationship with the billing practitioner, defined as having received a professional service within the previous 12 months, and beneficiaries would be required to consent to participation and to confidentiality terms given the group setting.
Clinical Laboratory Fee Schedule: CMS proposes conforming regulatory changes to the Clinical Laboratory Fee Schedule (CLFS) consistent with amendments made by the Consolidated Appropriations Act, 2026. These changes include updated data collection and reporting requirements and a phase-in of payment reductions of up to 15% per year through CY 2029. The next data reporting period for clinical diagnostic laboratory tests (CDLTs) that are not advanced diagnostic laboratory tests (ADLTs) is occurring from May 1, 2026, through July 31, 2026, based on applicable information collected from January 1, 2025, through June 30, 2025.
Request for Information on Duplicate Laboratory Testing, Imaging, and Interoperability: CMS issues a Request for Information (RFI) to gather input on addressing interoperability and duplicate testing concerns. CMS notes that diagnostic imaging and laboratory test results are frequently siloed within electronic health record (EHR) systems, which can lead to unnecessary duplication of services.
Medicare Prescription Drug Inflation Rebate Program: CMS proposes new policies for the Part B and Part D Drug Inflation Rebate Programs. The proposed rule clarifies the methodology for gap-filling Consumer Price Index for All Urban Consumers (CPI-U) data when data is unavailable. CMS also proposes to require 340B covered entities to submit certain data elements to the 340B Repository for Part D drugs beginning January 1, 2027.
Accounting for Overlap Between E/M Visits and Global Periods (Modifier -25): CMS proposes to reduce payment when a separately identifiable office/outpatient E/M visit is furnished by the same physician (or a physician in the same practice) on the same day as a procedure with a 0-, 10-, or 90-day global period. Under this proposal, the most expensive service (whether surgical or E/M) would be paid at 100%, and all other surgical procedures or E/M visits furnished on the same day would be paid at 50%. CMS first proposed a similar payment reduction in the CY 2019 PFS proposed rule as part of a broader suite of proposals to modify the E/M payment structure, but did not finalize it at that time after receiving significant opposition from commenters. CMS presently believes there are efficiencies and likely duplication of payment under the current methodology. According to CMS, the specialties that would experience the largest negative impact from this proposal include otolaryngology, dermatology, and podiatry.
E/M Visit Complexity Add-On: Transition from G2211 to Modifiers MOD1 and MOD2: CMS proposes to transition HCPCS code G2211 from an add-on code to a modifier (MOD1) that would be appended to the E/M base code. MOD1 would increase payment of the associated E/M code by 16%, rather than paying a flat rate, thereby maintaining an equal percentage increase across all E/M levels. CMS also proposes a second modifier (MOD2) exclusively for practitioners in Shared Savings Program ACOs and Long-term Enhanced ACO Design (LEAD) Model ACOs. CMS recently announced the LEAD Model, which will launch on January 1, 2027, and is designed to attract health care providers that have previously had limited participation in ACOs. MOD2 would increase payment of the associated E/M visit by 32%. This modifier recognizes the additional resource costs for practitioners providing longitudinal care within accountable care relationships, including total cost of care accountability, quality measure reporting, and care coordination. Use of MOD2 would be voluntary and available for all beneficiaries served by the practitioner, not limited to ACO-assigned beneficiaries.
Advance Care Planning: CMS proposes two new HCPCS codes (GACP1 and GACP2) for advance care planning services furnished by clinical staff under the direct supervision of the billing practitioner. Under this proposal, the existing CPT codes 99497 and 99498 would be used only for time personally spent by the billing practitioner on advance care planning.
Limiting Medicare Coverage of Certain Individuals: CMS proposes to implement statutory changes from Section 71201 of the Working Families Tax Cut legislation (Pub. L. 119-21). Under this proposal, Medicare eligibility would be limited to U.S. citizens and nationals, lawful permanent residents, Cuban and Haitian entrants, and Compact of Free Association (COFA) migrants. Individuals enrolled as of July 4, 2025 who do not meet these criteria would have an 18-month grace period, with coverage terminated on February 1, 2027. CMS projects that approximately 32,000 individuals would lose coverage, representing approximately 0.05% of total Medicare-aged enrollment. CMS estimates a 10-year reduction in Medicare spending of approximately $4.97 billion as a result of this provision.
Primary Care Comment Solicitations: CMS is seeking comments on how it might reconsider primary care service valuation to better support its objective of shifting the health care system toward a focus on preventive rather than reactive medicine, consistent with the Make America Healthy Again initiative. CMS identifies three specific topics for comment: (1) reconsidering relative primary care payment levels in the PFS; (2) understanding the payment implications of including technology in primary care; and (3) establishing prospective primary care payment in the Medicare Shared Savings Program and potentially in the original Medicare program broadly. CMS also notes that it is considering establishing distinct categories of office/outpatient E/M visits in future rulemaking, such as longitudinal care, acute care, and consultative visits, with distinctions based on the clinical purpose of the encounter and the associated resource costs.
Comments on the CY 2027 PFS Proposed Rule must be received by September 14, 2026. A final rule is expected later this year, with changes taking effect January 1, 2027. The proposed rule is available here, and the fact sheet is available here.
Reporter, Dennis Mkrtchian, Los Angeles, CA, +1 213 218 4046, dmkrtchian@kslaw.com
Beyond the Numbers - Key Takeaways from HHS-OIG's Spring 2026 Report
The HHS Office of Inspector General (OIG) recently published its Semiannual Report to Congress for the period October 1, 2025, through March 31, 2026. The report covers OIG’s oversight of more than $2.4 trillion in annual federal health care spending across Medicare, Medicaid, and related public health programs. During this period, OIG’s work generated $5.56 billion in total monetary impact, resulted in 604 criminal and civil enforcement actions, and led to the exclusion of 1,212 individuals and entities from federal health care programs. Despite the large reported monetary impact, this headline figure coincides with individual criminal, civil, and exclusion enforcement activity down approximately 25%, falling to its lowest level in at least two years.
The Report highlighted OIG’s focus areas over the last six months, combined with the recoveries and expected financial impact of OIG’s enforcement activity. While DOJ touted record-breaking False Claims Act (FCA) collections exceeding $6.8B in FY2025, which ended September 30, 2025, OIG’s report picks up on October 1, 2025. OIG’s headline figure touts a $5.56 billion total monetary impact from the period’s efforts, saying it returned $12.70 for every dollar the agency spent. However, OIG’s “total monetary impact” metric is a new financial tracking metric that was introduced in early 2025 that blends projected savings with amounts ordered or agreed to be repaid, not actual collections. This figure has been quite variable in recent reports, ranging from $16.61 billion to $2.43 billion before reaching the current $5.56 billion. Moreover, the reported criminal and civil actions fell to 604 (from 833) and exclusions continued a two-year decline from a prior high of 1,795. However, the Trump administration is focused on coordination and enhancing fraud enforcement, including the creation of the new Fraud Enforcement Division, so we do not expect this decline to reflect a larger trend.
Focus areas highlighted in the report include:
Enforcement: OIG reports that its investigative activity produced $4.3 billion in receivables, 317 criminal actions, and 287 civil actions. Notable prosecutions included a 15-year sentence and $452 million restitution order for the CEO of a telemedicine/DME fraud scheme exceeding $1 billion; prison sentences for wound graft company owners involved in more than $1.2 billion in fraudulent claims with hundreds of millions in kickbacks; and 20-year sentences for an insurance brokerage executive and marketing CEO for a $233 million ACA enrollment fraud scheme. These cases reflect DOJ and OIG’s sustained focus on telehealth, DME, and managed care schemes.
Medicaid and MFCU Activity: The report also highlights Medicaid Fraud Control Unit enforcement activity that resulted in 1,185 convictions, 674 civil settlements, and more than $2 billion in recoveries across all jurisdictions in FY2025. With Medicaid accounting for nearly one in five health care dollars, state-federal enforcement coordination remains robust. Indeed, Inspector General March Bell’s opening message noted that combating Medicaid fraud is “one of the most important issues OIG is focused on.” Bell remarked that the FY2025 metrics indicate that “there are high-performing MFCUs.”
This statement draws a contrast to OIG’s announcements earlier this summer that it was formally decertifying the state MFCU offices in New York and Hawaii due to their low levels of criminal enforcement.
Medicare Advantage and Risk Adjustment: Medicare Advantage and risk-adjustment coding is a dominant enforcement focus. Spotlighted False Claims Act settlements included $556 million from five Kaiser Permanente affiliates and $117.7 million from Aetna, both resolving whistleblower allegations of inflated diagnoses impacting risk adjustment. OIG also issued a Medicare Advantage Compliance Program Guidance identifying key risk areas: utilization management, prior authorization, marketing practices, and risk adjustment.
Improper and Inefficient Payments: CMS estimated FY2025 error rates ranging from 4.0-6.6% of payments, resulting in improper payments exceeding $95 billion across programs. OIG highlighted its efforts to prevent and detect improper payments, including examples such as $77.8 million in improper Medicaid payments in Colorado and $45.6 million in Maine for autism-related behavioral services due to inadequate state oversight, and $22.7 million in ineligible DME payments.
OIG also reports its cost savings recommendations wherein it identified $447.6 million in potential savings and issued 173 recommendations aimed at strengthening program performance and integrity through audits. OIG’s observations included the opportunity for $301.5 million in potential savings on opioid use disorder bundled payments where bundled rates exceeded actual service costs. OIG also investigated the rising cost associated with continuous glucose monitor payments, estimating that Medicare paid $377 million more than the suppliers’ acquisition costs.
Vulnerable Populations: OIG reported its focus on protecting “vulnerable populations” through enforcement focused on children and nursing homes. In nursing homes, OIG identified inappropriate antipsychotic use, including misdiagnosing residents with schizophrenia to mask antipsychotic prescribing or inflate quality ratings. OIG reported the exclusion of multiple individuals and entities, and the conviction of a nursing facility CEO who was sentenced to 90 months and ordered to pay $146 million for diverting Medicare/Medicaid funds from resident care. OIG also concluded that CMS’s program to address nursing home quality issues in the nation’s poorest performing facilities, the “Special Focus Facility program,” was ineffective, with nearly two-thirds of “graduated” facilities later exhibiting similar quality problems.
Opioids and Controlled Substances: OIG continues to focus on the prescription and distribution of controlled substances. Recent enforcement included exclusions of a physician (23 years) for pre-signed prescriptions and a pharmacy owner (27 years) for selling opioids without prescriptions, as well as a $650,000 settlement with a hospital and physicians for unsafe opioid prescribing patterns.
In sum, the OIG Spring 2026 Semiannual Report reflects a downward trend in individual enforcement activity, but signals the administration’s continued focus on top-line FCA recoveries and specific enforcement priorities, consistent with statements by DOJ officials and the Vice President’s Task Force to Eliminate Fraud. This administration continues to emphasize fraud investigations and enforcement, with particular attention on Medicare Advantage and state Medicaid dollars.
The full report is available here.
Reporter, Alana Broe, Atlanta, GA, +1 404 572 2720, abroe@kslaw.com
D.C. Circuit Affirms CMS’s Refusal to Discard Survey Data for MA Plan Survey Ratings
On July 14, 2026, the D.C. Circuit affirmed the D.C. District Court’s summary judgment ruling for CMS denying Alignment Healthcare’s (Alignment) challenge to CMS’s refusal to discard survey data as arbitrary or capricious.
Alignment is a health insurance company that offers Medicare Advantage plans, which are subject to a rating system that includes the use of an annual survey of enrollees. In September 2024, Alignment contacted CMS contending that the ratings for two of its plans were inaccurate because some Spanish-speaking customers received surveys in English, contrary to Alignment’s request of their preference. Specifically, Alignment disputed preliminary Star Ratings for two of its contracts after Spanish-language survey responses dropped significantly between 2023 and 2024 despite a slight increase in the percentage of Spanish-speaking members.
Alignment contended that the decline in Spanish-language responses indicated either a sampling bias or a survey administration error in which Spanish-speaking members did not receive surveys in their preferred language. Alignment asked CMS to examine the samples, suppress the survey results, or mark certain measures as having very low reliability. After reviewing the data, CMS concluded that the results were consistent with random sampling, typical response patterns, and proper survey administration and denied Alignment’s request to disregard the survey results. Alignment challenged CMS’s decision under the Administrative Procedure Act in D.C. District Court. The District Court granted summary judgment for CMS, and Alignment appealed to the D.C. Circuit.
On appeal, the D.C. Circuit rejected Alignment’s argument that CMS’s protocols required Spanish-language questionnaires to be sent to all Spanish-speaking enrollees and that the survey vendor violated those protocols by sending English surveys to enrollees who preferred Spanish. The D.C. Circuit held that, even assuming Alignment’s Spanish-language request was binding on the survey vendor, Alignment failed to show that the survey vendor disregarded the request or that CMS acted in a manner that was arbitrary or capricious in accepting the survey results. The D.C. Circuit further held that CMS reasonably found no evidence of survey administration error after reviewing the data and consulting the vendor and rejected Alignment’s contention that CMS was obligated to discard the results for the impacted contracts.
The D.C. Circuit also dispatched Alignment’s ancillary arguments: it found that Alignment forfeited its Chenery objection by failing to raise it in the District Court; held that CMS’s approach did not violate the private nondelegation doctrine because CMS retained ultimate authority over whether to include survey data in Star Ratings; and rejected the claim that CMS failed to treat like cases alike, noting that Alignment pointed to no instance in which CMS suppressed survey results in similar circumstances.
The decision carries several practical implications for participants in CMS-administered quality measurement programs. First, the D.C. Circuit reaffirmed that judicial review of CMS decisions involving “complex judgments about sampling methodology and data analysis” is particularly deferential, signaling that challenges to CMS quality determinations—whether involving Star Ratings, Consumer Assessment of Healthcare Providers & Systems surveys, or other performance metrics—face a high bar. Second, the D.C. Circuit’s Chenery forfeiture holding underscores the importance of raising all substantive and legal arguments during the administrative process itself; Alignment’s failure to frame its Protocols-based argument during the plan preview period proved fatal on appeal. Third, the D.C. Circuit emphasized that the party challenging agency action bears the burden of proof—meaning that merely raising suspicion of data irregularities, without pointing to concrete evidence of error in the administrative record, will not suffice.
The full text of the decision is available here.
Reporter, Kasey Ashford, Washington, D.C., +1 202 626 2906, kashford@kslaw.com
Labcorp Agrees to $14.5 Million Settlement to Resolve False Claims Act Allegations Involving Medically Unnecessary Drug Testing
On July 15, 2026, the Department of Justice (DOJ) announced that Laboratory Corporation of America (Labcorp), one of the nation's largest clinical diagnostics companies, agreed to pay $14.5 million to resolve allegations that it violated the False Claims Act by submitting false claims to Medicare Part B for medically unnecessary urine drug testing (UDT). The settlement centers on a testing panel offered by Labcorp known as “ToxAssure Comprehensive,” which the government alleged resulted in the routine submission of unnecessary claims over a nearly six-year period.
The Allegations
According to the government's allegations, from January 1, 2018, through November 22, 2023, Labcorp routinely submitted claims to Medicare for both presumptive and definitive urine drug testing performed simultaneously on the same patient, using the same urine sample, on the same date of service. Labcorp billed Medicare using CPT Code 80307 for presumptive UDT and the highest-tier definitive HCPCS Code G0483 for definitive UDT each time the ToxAssure Comprehensive panel was performed.
As background, presumptive UDT is a preliminary screening method that detects the presence or absence of certain drug classes subject to testing thresholds, while definitive UDT is a more advanced method that identifies individual substances and their specific concentrations. Under Medicare’s payment structure, laboratory-based presumptive testing is reimbursed at a flat rate regardless of the number of drug classes tested, and definitive testing is reimbursed at a flat rate for 22 or more drug classes.
The ToxAssure Comprehensive panel consisted of a preselected combination of presumptive UDT for certain substances and direct-to-definitive UDT—meaning definitive testing without any prior presumptive test—for other substances. For several of the substances tested on a direct-to-definitive basis, a presumptive testing option existed, but Labcorp performed its definitive tests without first performing a presumptive test to inform the necessity of definitive testing for that substance. The United States alleged that the full panel, as billed, resulted in the submission of medically unnecessary claims to Medicare for some patients.
Settlement Terms and Admissions
As part of the settlement, Labcorp admitted, acknowledged, and accepted responsibility for the billing conduct described above. Labcorp also represented that it has ceased billing Medicare for the combination of codes 80307 and G0483 for beneficiaries tested using the ToxAssure Comprehensive panel. Notably, Labcorp received credit under the DOJ’s guidelines for taking disclosure, cooperation, and remediation into account in False Claims Act cases, pursuant to Justice Manual §4-4.112.
Enforcement Trends
The Labcorp settlement is part of a broader pattern of DOJ enforcement activity focused on health care fraud under the False Claims Act. Earlier this year, the Administration created the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to strengthen efforts to combat fraud, waste, and abuse in federal programs. These initiatives complement the additional prosecutorial resources recently directed to the Health Care Fraud Unit, which has secured convictions in all nine trials it has conducted so far in 2026.
The coordinated investigation behind the Labcorp resolution, which involved DOJ’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the District of Massachusetts, in conjunction with HHS-OIG, exemplifies the multi-agency approach the DOJ has increasingly employed to identify and pursue billing fraud.
Moreover, the Labcorp settlement underscores several trends that health care providers and clinical laboratories should monitor. First, the DOJ’s crediting of Labcorp’s cooperation and remediation suggests that early disclosure and corrective action remain meaningful mitigating factors in FCA resolutions. Second, the establishment of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division indicates that health care fraud enforcement will remain a DOJ priority.
The DOJ’s press release is available here.
Reporter, Priya Sinha, Atlanta, GA, +1 404 572 3548, psinha@kslaw.com
Upcoming Events
What’s Happening With the NSA?
- July 30, 2026, 1:00 – 2:00 P.M. ET
- Virtual
Many providers rely on the No Surprises Act Independent Dispute Resolution (IDR) process to challenge low out‑of‑network payments. But the system is under increasing strain. Plans are suing providers for submitting allegedly ineligible disputes, and some are outright refusing to pay awards. At the same time, CMS‑appointed IDR entities are still struggling to manage the high volume of disputes.
This program will offer an update on the IDR process and key legal developments, including the long‑awaited IDR Operations Final Rule, recent trends in CMS IDR outcomes, new caselaw on the enforceability of IDR decisions in federal court, whether a circuit split may prompt Supreme Court review, the growing consensus among federal courts that health plans do not have a cause of action against providers for allegedly fraudulent IDR submissions, and alternative strategies for noncontracted provider underpayment disputes, including potential avenues for relief in state courts.
You do not have to be a client to attend, and there is no charge. RSVP by July 29. For questions, contact Sydney Forte.
Editors: Chris Kenny and Ahsin Azim
Issue Editors: Christopher Jew and Marcia Foti