Medicare Advantage
GAO: VA and Medicare Advantage Improper Payments Expose Risk Gaps
GAO found unfinished fraud-risk work at VA and CMS, including delayed Medicare Advantage RADV audits. The reported improper-payment figures are not fraud estimates.
Healthcare compliance
CMS compliance
CMS Nursing Home Risk-Based Survey: What Changes in 2026
CMS’s new survey model uses fewer resources at selected nursing homes. Learn how qualification, disqualification, state-held complaint data, rating volatility, and revalidation affect survey readiness.
Healthcare AI
The IRB Exemption Pressure-Test: 3 Questions for AI Governance Teams
A Mayo Clinic whistleblower suit alleges an AI study bypassed IRB review — but the real story is structural: who holds exemption authority, and what happens when staff disagree. Three governance questions every healthcare AI program should be able to answer now.
Prior authorization
CMS-0057-F Prior Authorization Rule: No Verification Behind the Numbers
CMS-0057-F requires payers to publicly post prior authorization metrics — but CMS's own rule text confirms no independent audit or certification process backs the disclosure. The insurance industry's voluntary pledge has the identical gap.
Healthcare compliance
H.R. 9396 Prior Authorization Accountability Act: Disclosure Without Accuracy Verification
H.R. 9396 would require health plans to publish PA denial rates, appeal outcomes, and AI decision metrics starting 2027 — but contains no attestation, audit, or accuracy framework. Here's what compliance teams need to watch before rulemaking closes.
PBM oversight
Tennessee FAIR Rx Act Targets Pharmacy-Insurer-PBM Ownership
Tennessee’s final FAIR Rx Act is narrower than early drafts, but it still targets the pharmacy-insurer-PBM stack. CVS is suing to block the law before its July 2028 trigger.
Healthcare compliance
HHS AERO and Single Audit Risk: What Old Findings Now Signal
HHS AERO applies AI analytical tools to years of Single Audit history, putting unresolved findings, delinquent submissions, and corrective-action records back in view.
Healthcare compliance
Federal IDR Final Rule: What Changed Before Payment Review
Federal agencies finalized new IDR operations requirements under the No Surprises Act, shifting more attention to claim communication, portal timing, batching, payer identity, and eligibility review.
Healthcare compliance
Medicare Part D Payment Data Gap: What HHS OIG Could Not Trace
HHS OIG found similar net drug costs for selected Medicare Part D drugs, but different payment paths and incomplete pharmacy-level DIR traceability.
Healthcare compliance
DME Fraud Bill Puts Medicare Claims Screening Under Scrutiny
H.R. 8871 would create a 90-day claims-submission period for certain Medicare DME items and require GAO to examine MAC screening technology.