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.
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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.
Author: Tiffany Ferguson, LMSW, CMAC, ACM | August 25, 2026
Ask a group of hospital leaders whether their organization has a Utilization Review (UR) or a Utilization Management (UM) department, and the answers will likely vary. In many organizations, the terms are used interchangeably. Job titles may include UR nurse, UM specialist, UM director; you get the point. This occurs even when the individuals are performing essentially the same work.
But are UR and UM actually the same? There is an important distinction between the two, and that distinction may be becoming more important as healthcare moves further away from managing individual encounters towards managing total utilization and episodes of care.
At its most basic level I have always considered utilization review as micro practice, while utilization management as macro practice. What I mean is, utilization review focuses primarily on the individual patient encounter. Does this patient require inpatient hospitalization? Does the documentation support the level of care? Does the case require escalation to a physician advisor? Has the payer authorized the services being provided?
The term ‘utilization review’ also has a specific regulatory foundation. Medicare’s Conditions of Participation at 42 CFR §482.30 require hospitals to maintain a utilization review plan addressing the medical necessity of admissions, duration of stays, and professional services furnished. Yet like all things from the time of 482.30 being written, we have naturally evolved beyond the term utilization review, into the management arena.
Traditional UR has largely been built around the hospital encounter. A patient arrives in the emergency department, a decision is made regarding hospitalization, and UR evaluates whether the patient meets the requirements for inpatient or outpatient care, often with observation services. Concurrent review then follows the patient through hospitalization. That model made sense when the hospital encounter was largely evaluated and reimbursed as an individual event. Increasingly, however, hospitals are operating in an environment where the financial and clinical consequences of utilization extend well beyond a single admission or even payer demands.
Consider an uninsured patient. There may be no payer authorization to obtain and no insurance company requesting concurrent clinical reviews. Under our old model, we may ignore this case, but from a utilization management perspective, this case is total financial risk to the organization.
The same evolution can be seen in CMS payment models. Models such as CJR-X will reinforce the importance of looking beyond the walls of the hospital and considering utilization across an episode of care. When organizations assume greater accountability for the cost and outcomes associated with an episode, utilization decisions cannot be isolated to whether the initial hospital admission met criteria. This is going to push the UR to UM model as we are evaluating length of stay, post-acute utilization, readmissions, avoidable emergency department use, and patient progression.
While UR can help to determine whether the individual service was appropriate. Maybe now it is the UM professional who asks whether the entire pattern of care was appropriate. Thus, an adaptive UM program requires data, physician engagement, case management, revenue cycle, CDI, finance, nursing, operational leadership, and utilization professionals working from a shared strategy.
This article was originally published on RACmonitor.
Author: Christine Geiger, MA, RHIA, CCS, CRC | August 25, 2026
Thanks to all our attendees to the IPPS Masterclass this week. We shared a lot of information on the new ICD-10-CM and PCS codes, changes to MS-DRGs and exciting new technologies that were approved for FY27 add-on payments. Educating yourself and your coding team on all the final rule changes ensures you can confidently hit the ground running when you start processing those Oct. 1 discharge and service dates.
Other than being familiar with the impending changes, what else can we do to make sure our coding teams are as prepared as possible? One easy thing to do is to check and make sure your new coding books have been ordered and to watch for delivery updates. A quick Amazon search last week was showing mid to late October deliveries for some publisher’s CM books.
Make sure your coders are aware of the changes and have a procedure in place until their FY27 books arrive. Once the books have arrived, do an update check and make sure the changes are accurately reflected in the publication. It is not unheard of to have printing errors…another crucial reason coders should familiarize themselves on the new changes.
If you have an integrated or standalone encoder, do you know when the updates will be loaded? Will there be any related downtime? Will it be before or after Oct. 1? Will the coding workflow be affected, and if so, how? While these changes may be out of your control, the way you prepare yourself is not.
Some facilities have one designated coder be responsible for either attending an educational webinar or reviewing the final rule and then sharing what they learned with their team. It is vital that each coder on the team is aware of all new changes that have a direct impact on their daily work. This process will look different depending on how big your team is and where they are located. One of the great things about being a coder is the ability to work remotely. Tools such as Microsoft TEAMS and GoToMeeting make this process easier.
If the coders work remotely but are close to a main hospital or other corporate location, they can choose to have an in-person training. In person is always a great idea if it is possible. Getting everyone together, even virtually, is great for team cohesion. Another idea is to include others who might benefit to your education and training. If you know people in other areas of your institution or organization who may perform the coding for other areas or departments, invite them to your sessions.
This can be a great way to develop those relationships within your organization and make your team the “go-to” for questions on coding issues.
Let’s say your team has learned about the new codes and MS-DRG changes, you have verified books and technology updates are ready to go, is there anything else? As part of your review of the changes, are there any that stand out for your facility or group? Does your team do obstetric coding? There are new codes for ectopic pregnancies to consider. Are you seeing the new specificity documented? Is there an opportunity for physician outreach and education? Similarly, we have some new specific secondary malignancy codes for pharynx and larynx. Do you have physicians who routinely document “head and neck mets” without further specificity? Do not wait until mid-October to reach out or send queries. Open those lines of communication now with your providers.
Also, do not assume that everyone knows what you know. I recently saw a handwritten provider note that documented UTI as a diagnosis with an additional notation of 599.0. While that provider was probably trying to be helpful, they missed the memo over a decade ago that we have moved on to ICD-10!
Coders have the opportunity and the obligation to be that expert voice sharing our knowledge and insight with all members of the healthcare team.
This article was originally published on RACmonitor.
August 20, 2026
UnitedHealthcare is expanding access to its child and family behavioral coaching program, making it available to 13 million commercial members.
This article was originally published on Fierce Healthcare.
Author: Adam Brenman | August 19, 2026
A federal court ruling is set to change how health plans calculate a key payment benchmark under the No Surprises Act (NSA), with implications for insurers, providers, and the law’s dispute resolution process.
Last week, the US Court of Appeals for the Fifth Circuit issued its long-awaited decision in a case called “TMA III,” following a rehearing by the full court in September of last year. The case challenged provisions of the federal government’s 2021 Interim Final Rule regulating calculation of the NSA’s qualifying payment amount, or QPA. The QPA is generally based on the median of applicable contracted rates and plays an integral role in payments and disputes involving out-of-network care.
The court largely sided with provider plaintiffs on two of three disputed elements of the QPA’s calculation methodology: the so-called “ghost rates” and certain bonuses, incentives, and other payment adjustments, while upholding the government’s approach on a third issue involving inclusion of single-case agreements.
Ghost rates are contracted rates for services that a provider doesn’t actually perform or may never provide. As an example, a contract containing a rate for a service outside a provider’s normal practice. Under the challenged methodology, such rates could be incorporated into the median used to determine a QPA. The court concluded that these rates cannot be included merely because they appear in a contract.
From a provider perspective, including ghost rates can artificially lower QPAs because providers have little incentive to negotiate meaningful rates for services they don’t perform. The court’s decision could therefore result in some higher QPAs by removing those rates from the calculation. Providers have also argued that inaccurate benchmarks can influence reimbursement offers and arbitration outcomes connected to the NSA’s IDR process.
The ruling also addressed bonuses, incentives, and other payment adjustments – something the federal methodology had categorically excluded from QPA calculations. But the Fifth Circuit found that approach unlawful, concluding that applicable compensation must be accounted for when necessary.
For health plans and federal regulators, the ruling presents a different set of considerations. Changing the QPA’s calculation methodology would force plans to modify QPAs as well as current systems and processes. Federal officials warned the court of exactly this – that vacating, or removing, the challenged rules would require extensive recalculations. However, the court determined that vacating the provisions would not be unduly difficult and indicated that agencies could temporarily permit plans to continue using existing QPAs while new amounts are calculated, as they did while the case was pending.
Now, keep in mind, the decision was not a complete victory for providers. The Fifth Circuit upheld the exclusion of one-off, single-case agreements from QPA calculations. These agreements can involve atypical reimbursement arrangements, and their inclusion could increase benchmarks beyond what an insurer typically pays for an in-network service.
Additionally, to add a bit of context, the ruling arrives as the NSA IDR arbitration system has taken on a much larger role than initially anticipated. The Centers for Medicare & Medicaid Services (CMS) and various news outlets have recently noted that providers prevail in more than 80 percent of resolved disputes, highlighting the significance of the benchmarks used during the dispute process.
The longer-term effects of the ruling remain uncertain. The overturned provisions of the QPA calculation methodology concerning ghost rates and bonuses and incentives have been vacated, leaving a void, and CMS has already said it anticipates issuing updated guidance shortly.
In the immediate future, the impact may be limited because existing plan QPAs likely will continue being used temporarily. But over time, recalculating QPAs to align with the court’s ruling may affect how both plans and providers approach the federal arbitration process.
As CMS considers its next move, stakeholders should be watching closely to determine how all this impacts reimbursement, dispute resolution, and further implementation of the NSA.
References:
This article was originally published on RACmonitor.
Author: Timothy Powell, CPA, CHCP | August 19, 2026
Artificial intelligence companies developing healthcare revenue-cycle tools need large volumes of real claims data. Two of the most valuable sources are the 837 electronic claim and the 835 electronic remittance advice.
The 837 reports what the provider billed. The 835 reports how the payer adjudicated that claim, including payments, denials, adjustments, deductibles, and coinsurance. When properly matched, these transactions can help train AI to identify underpayments, predict denials, estimate collectability, and recognize payer behavior.
Where Can AI Companies Obtain the Data?
The most practical sources are organizations already authorized to receive and maintain the transactions:
An AI company can contract with one of these organizations to develop or operate a defined application. Because the work may involve creating, receiving, maintaining, or transmitting protected health information (PHI), the AI company will frequently be a business associate.
The parties must execute a business associate agreement (BAA) specifying the permitted uses of the data, required safeguards, approved subcontractors, breach-reporting responsibilities, and what happens to the information when the engagement ends.
A BAA is Not Permission to Build any Model
Signing a BAA does not give an AI company unlimited authority to use a hospital’s claims.
If an AI vendor receives PHI to identify denials for Hospital A, it cannot automatically add those claims to a general model sold to Hospitals B through Z. The use must be authorized by the agreement and permitted by the HIPAA Privacy Rule.
Contracts should address model training directly, including the following:
De-identification Creates Another Pathway
AI companies may use properly de-identified 835 and 837 data without treating it as PHI. HIPAA recognizes two de-identification methods: Safe Harbor and Expert Determination.
Safe Harbor requires the removal of specified identifiers. Expert Determination permits a qualified expert to determine that the risk of identifying an individual is very small.
Removing patient names is not sufficient. Claims may contain medical-record numbers, claim-control numbers, subscriber identifiers, service dates, addresses, free-text fields, rare diagnoses, and unusual combinations of procedures.
Safe Harbor may also eliminate dates needed to train timely-filing or payment-delay models. Expert Determination may preserve more useful relationships while still reducing re-identification risk.
Limited and Synthetic Data
A limited data set is not fully de-identified. It remains PHI, requires a data-use agreement, and may be used only for specified purposes such as research, public health, or healthcare operations.
Synthetic 835 and 837 files provide another option. They are useful for teaching transaction structure and testing software, although they may not accurately reproduce real payer behavior.
The Correct Division of Responsibility
AI companies can obtain claims data through carefully defined provider, payer, clearinghouse, or revenue-cycle relationships. They can also license properly de-identified data or generate synthetic transactions.
The essential rule is simple: standardized data is not public data. Permission to process an 835 or 837 for one customer is not necessarily permission to use it to train a commercial AI product.
Healthcare organizations must control the data, legal agreements must control its use, and AI companies must design their models around those limitations.
This article was originally published on RACmonitor.