Pharmacy Benefit Management
Florida’s PBM lawsuit against Prime Therapeutics and Express Scripts raises a larger oversight question: who controls pharmacy reimbursement, and can plan sponsors trace reported savings to net plan economics?
AI Governance
A PLOS review found only 3 of 1,357 FDA-authorized AI medical devices had patient-centered outcome evaluations. Here’s what FDA status proves—and what evidence still needs separate review.
Medicaid policy
CMS’s ABA toolkit gives states a nonbinding framework for treatment intensity, authorization, documentation, payment, and program integrity. It creates no national treatment-hour cap; implementation will depend on state or program action.
Healthcare compliance
A House committee advanced H.R. 9393, but the central implementation issue remains unresolved: CMS can enforce publication rules without independently proving that every reported price is contractually accurate.
Medicare Advantage
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.
CMS compliance
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
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 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 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’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 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 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.