Medicare & Medicaid, week of Aug 23, 2026

CMS reports $1.6 billion in Medicare laboratory program integrity actions across revocations, suspensions, recoupments and referrals

What changed

CMS announced August 28 that its Medicare laboratory program-integrity work had stopped more than $1.6 billion in potentially improper payments. The total combines four different measures: $732 million in savings associated with revoking 157 providers, over $500 million halted through 185 suspensions arising from an investigation of 600 laboratories, more than $276 million recouped from 442 identified overpayments, and $127 million prevented through 85 contractor law-enforcement referrals. Only the recoupment category describes money already paid and then recovered. The announcement does not establish that the entire aggregate was recovered or that fraud was adjudicated for every associated claim.

The agency describes using artificial intelligence and machine-learning models to flag unusual Medicare fee-for-service billing before payment, including tests without a supporting ordering-provider relationship, unperformed services and upcoding. Named areas include pathogen detection, high-complexity drug tests and genetic testing. One example involved fourteen nonoperational laboratories and more than $24 million billed, with $12 million held under suspension and an additional $7 million recouped. Two Texas examples involved $1.2 million and $1.9 million in denied claims followed by suspension or enrollment action. These accounts illustrate different enforcement tools and stages; the release creates no new provider reporting duty. Any organization-wide sampling or enrollment review is a recommended response to the signal, rather than a mandate in this announcement.

Why it matters

The distinct categories matter when interpreting the size and timing of program-integrity exposure. As an operational inference, laboratory compliance teams can use the named billing patterns to choose monitoring samples, without treating the announcement as a finding against their own laboratory.

Response type

Validate

Confidence

High

Who this affects

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Compliance, Revenue Cycle, Coding, Clinical Operations, Provider Enrollment, Finance, Legal

What to do nextAs a self-directed review, sample the organization’s laboratory claims in the named test categories for clinical support, the ordering relationship and evidence the service occurred. Check relevant laboratory enrollment records and assign follow-up for discrepancies. Present any proposed monitoring change as an internal control decision, not a new requirement imposed by this release.

1. Pull twelve months of laboratory claims in pathogen detection, high complexity drug testing and genetic testing, and chart the monthly volume and dollar trend by billing identifier. Revenue Cycle · due Sep 13, 2026
2. Sample the highest volume test codes and confirm an ordering provider relationship, a signed order, and a medical necessity record for each sampled claim. Compliance · due Sep 27, 2026
3. Inventory every Medicare laboratory billing identifier the organization controls or manages, including joint ventures and managed arrangements, and confirm enrollment data and revalidation ownership. Provider Enrollment · due Sep 27, 2026
4. Confirm the process for receiving and escalating a Medicare payment suspension or revocation notice, including who is notified within one business day and who leads the corrective response. Compliance · due Oct 4, 2026
5. Report the volume trend, the sample error rate, and the enrollment inventory to the compliance committee with a recommendation on prepayment self monitoring. Compliance · due Oct 18, 2026

Permalink: #cms-medicare-laboratory-payment-integrity-actions · Development ID GC-2026-0009

Noridian finalizes two MolDX coverage policies for California effective October 12 and retires the thrombophilia policy October 11

What changed

Noridian announced August 27 that two MolDX local coverage determinations for Jurisdiction E, including California, will take effect for services on or after October 12. L40242 addresses hereditary thrombophilia testing, with billing article A60272; L40222 addresses non-next-generation-sequencing targeted molecular panels used to guide cancer therapy, with article A60239. Noridian separately announced retirement of L36155, its hypercoagulability and thrombophilia policy covering Factor V Leiden, Factor II prothrombin and MTHFR, effective October 11. The retirement and new-policy dates need to be mapped to service dates, rather than assuming an order placed earlier automatically uses the former coverage basis.

The finalized hereditary-thrombophilia criteria require qualifying clinical circumstances, a result that guides management, appropriate validated genetic content and MolDX technical assessment, with limits on repeat testing. The non-NGS cancer-panel policy also requires all stated criteria: the result must inform treatment, the method must meet the specified feasibility or turnaround conditions, and validation and technical assessment requirements still apply. It expressly warns that reference to a test does not automatically imply coverage. Laboratory menus and medical-necessity checks therefore need the operative indications and associated coding articles, rather than only a replacement LCD number.

Why it matters

The effective and retirement dates create a defined transition for the coverage rules applied to services. Orders, laboratory information and billing screens should support the appropriate service-date policy and its clinical conditions, rather than treating finalization as unrestricted coverage.

Response type

Implement

Confidence

High

Who this affects

Health systems, Provider networks

Jurisdiction

Federal, California, Hawaii, Nevada

Primary owner

Coding

Affected functions

Coding, Revenue Cycle, Clinical Operations, Compliance, Utilization Management, HIM/CDI

What to do nextReview L40242, L40222 and articles A60272 and A60239 before the October transition. Map service dates, test menus, ordering documentation and coverage screens to the finalized criteria. Have the appropriate billing and clinical owners assess any applicable beneficiary-notice duties instead of assuming every test is covered or denied from its name.

1. Obtain L40242, L40222 and billing and coding articles A60272 and A60239, and record the covered indications and coding requirements for each. Coding · due Sep 11, 2026
2. Map the current thrombophilia and non next generation sequencing targeted panel test menu, in house and send out, against the finalized indications and list every test that loses or changes coverage. Clinical Operations · due Sep 25, 2026
3. Update the laboratory compendium, order sets, and medical necessity screening logic so the change takes effect on October 12, 2026 and the retired L36155 basis stops applying on October 11, 2026. IT · due Oct 5, 2026
4. Decide and document the advance beneficiary notice position for tests that become non covered, and brief the ordering services in writing. Revenue Cycle · due Oct 9, 2026
5. Audit a sample of thrombophilia and targeted panel claims in the first four weeks after the effective date and report the denial rate. Compliance · due Nov 13, 2026

Permalink: #noridian-moldx-lcd-finalization-jurisdiction-e · Development ID GC-2026-0011

CMS proposes a new annual Acute Hospital Care at Home reporting requirement, comments close October 26

What changed

CMS’s August 27 Paperwork Reduction Act notice proposes a new Acute Hospital Care at Home Quantity, Intensity, and Mix of Services data collection, CMS-10971. It opens a sixty-day comment opportunity ending October 26, before submission to the Office of Management and Budget for approval. The tool would quantify services furnished to hospital-at-home patients, including clinician visits, food services and pharmacy services. The notice describes an annual collection and estimates 365 respondents, 13,000 annual responses and 13,000 annual burden hours. Those are estimated totals for the collection, not thirteen thousand hours per hospital.

The notice ties the work to section 6210(c) of the Consolidated Appropriations Act, 2026 and explains that CMS will use the information to report to Congress. Its scope includes patients admitted from an emergency department and patients transferred from an inpatient hospital unit under the initiative. Hospitals participate through waivers at the CMS Certification Number level. CMS invites input on necessity, usefulness, burden estimates, clarity and ways technology could reduce reporting effort. Because this is a request for a new control number, the proposed data fields and burden should be evaluated separately from any claim that an approved collection is already in operation.

Why it matters

Participating programs can assess whether existing records support the proposed counts while the collection is still open for comment. The notice establishes a proposal and estimates, so planning should not presume a final operational reporting requirement or an approved start date.

Response type

Comment

Confidence

High

Who this affects

Health systems

Jurisdiction

Federal

Primary owner

Clinical Operations

Affected functions

Clinical Operations, Compliance, Quality, HIM/CDI, Finance, Case Management

What to do nextConfirm hospital-at-home participation and ask the program’s data owners how the proposed clinician, food and pharmacy service counts could be produced. Compare the estimated effort with actual systems and decide whether to submit comments by October 26. Monitor separately for OMB approval and implementation instructions.

Permalink: #cms-acute-hospital-care-at-home-qims-data-collection · Development ID GC-2026-0010

Medi-Cal requires quarterly validation of the public fee for service provider directory beginning October 1, 2026, with Provider Portal Transaction Center access at stake

What changed

DHCS’s August 26 Medi-Cal notice says Provider Portal administrators must complete all Public Fee-For-Service Provider Directory survey questions within forty-five days beginning October 1. The same update or validation duty recurs each quarter, under the cited federal directory provision. Administrators must state whether each location accepts new fee-for-service patients, managed care patients or both, then save the directory after reviewing and answering every question. The notice gives the start and length of the window rather than a separate calendar end date.

The announced consequence is organization-wide: all users lose Provider Portal Transaction Center access if the required quarterly update is not completed. A processor who loses access must contact the organization’s portal administrator to update the directory and restore it. DHCS lists the Telephone Service Center for access problems and the Provider Enrollment Division’s inquiry channel for other directory questions. Naming a primary and backup administrator and checking service-location responses with patient access are practical controls suggested by this access dependency; the notice itself does not prescribe that internal staffing structure.

Why it matters

The directory update affects more than the person completing it because the stated access consequence reaches every Transaction Center user in the organization. Accurate location-level answers and a recurring owner can reduce avoidable access disruption.

Response type

Implement

Confidence

High

Who this affects

Health systems, Provider networks

Jurisdiction

California

Primary owner

Provider Enrollment

Affected functions

Provider Enrollment, Revenue Cycle, Compliance, IT, Patient Access

What to do nextConfirm the organization’s portal administrators and prepare the service-location answers before October 1. Assign a primary and backup owner for the recurring quarterly update, save the completed directory and retain confirmation. Use the stated administrator and support channels if access is lost.

1. Inventory every Medi-Cal Provider Portal organization identifier the organization holds and identify the current administrator for each. Provider Enrollment · due Sep 18, 2026
2. Name a primary and a backup administrator per organization identifier and confirm both can reach the Provider Portal Directory survey. Provider Enrollment · due Sep 25, 2026
3. Confirm with patient access and the service line owners, per service location, whether the location is accepting new fee for service patients, managed care patients, or neither. Patient Access · due Oct 9, 2026
4. Complete and save the first directory validation inside the window that opens October 1, 2026, and record the submission date. This target date sits well inside the 45 day window rather than at its end. Provider Enrollment · due Oct 31, 2026
5. Put the validation on a recurring quarterly calendar with the named owners, and confirm the escalation path if Provider Portal Transaction Center access is lost. Revenue Cycle · due Nov 13, 2026

Permalink: #medi-cal-public-fee-for-service-provider-directory-quarterly-validation · Development ID GC-2026-0015

October Medicare laboratory, EDI and physician-fee updates have distinct applicability and systems dates

What changed

CMS’s August 27 MLN Connects newsletter describes October 1, 2026 clinical laboratory fee schedule and CLIA updates, including annual and quarterly CLIA edits, new waived-test updates and new or deleted CPT codes. It also points home-health users to the October grouper release, version 07.2.26. The official August 27 R13934OTN listing, CR 14429, identifies the October HIPAA EDI front-end update with October 5 implementation. Separately, R13929CP, CR 14588, implements the October Medicare Physician Fee Schedule Database changes on October 5. That instruction carries a January 1, 2026 general service effective date but includes record-specific exceptions in its code attachment, so not every individual code change starts on the same date.

The physician-fee update changes payment-file records and directs contractors not to search for previously paid claims to retract or retroactively pay them; contractors must adjust affected claims brought to their attention and give providers 30 days’ notice before implementing the changes. The October 5 systems release therefore does not guarantee that all earlier affected claims will be found or adjusted automatically. Revenue-cycle planning must distinguish the laboratory October 1 applicability, the fee database’s general and record-specific service dates, and the separate October 5 EDI and fee-system work, while assigning the home-health grouper to its own application owner.

Why it matters

Different service, claim-received and systems dates can affect which edits or payment records apply to a claim. A release calendar alone cannot demonstrate accurate pricing, correct claim routing or completion of retrospective adjustments.

Response type

Implement

Confidence

High

Who this affects

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, IT, Coding, Finance

What to do nextAssign owners for laboratory/CLIA, EDI, physician-fee and home-health changes. Verify the applicable code-record dates and installed versions, reconcile representative claims, and bring affected physician-fee claims to the MAC rather than assuming an automatic search.

Permalink: #october-2026-medicare-claims-processing-updates · Development ID GC-2026-0012

2027 Medicare HCPCS releases and $0.270 clotting-factor fee have separate service and system dates

What changed

CMS issued R13937CP on August 27 under CR 14580 to set the 2027 clotting-factor furnishing fee at $0.270 per unit. The fee applies to dates of service beginning January 1, 2027; contractor implementation is January 4. CMS includes the furnishing fee in the published national clotting-factor payment limits. Where the payment limit is absent from the average-sales-price or not-otherwise-classified pricing files and separate payment for the factor is allowed, contractors add the furnishing fee separately. The fee is separately payable only when its costs are not already paid through another payment system, so the update does not authorize duplicate reimbursement.

The separate August 27 R13938CP, CR 14586, gives the download and implementation instructions for the complete 2027 quarterly HCPCS files, including existing, new, revised and discontinued codes. Effective dates are January 1, April 1, July 1 and October 1; the corresponding implementation dates are January 4, April 5, July 5 and October 4, 2027. CMS expects files approximately six weeks before each quarter and directs contractors to obtain them through its cloud process after notification, test and load the releases, and follow instructions for corrected files. This annual instruction replaces the former quarterly change-request process; it does not itself establish a new coverage policy for every code in the files.

Why it matters

A January 4 systems milestone does not move the furnishing fee’s January 1 service applicability or the effective dates of later HCPCS quarters. Pricing and code-file ownership must cover the full year.

Response type

Implement

Confidence

High

Who this affects

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, IT, Coding, Finance

What to do nextAssign pharmacy/revenue-cycle review of the $0.270 furnishing fee for January 1 onward services, checking whether it is already included in the factor payment limit. Schedule HCPCS file receipt, testing and implementation for each quarter and retain separate effective-date and systems-date controls.

Permalink: #january-2027-medicare-hcpcs-file-and-clotting-factor-updates · Development ID GC-2026-0014

Medicare colorectal biomarker coverage: June 8 effective date, January 4 claims implementation

What changed

CMS issued R13921NCD and R13921CP on August 27 under CR 14581, with coverage effective for services on or after June 8, 2026, and claims-system implementation on January 4, 2027. NCD 210.3 covers noninvasive colorectal biomarker screening once every three years when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist who will use the results to manage the patient. Patients must be aged 45 through 85, asymptomatic, and at average risk. The exclusions include a personal history of adenomatous polyps, colorectal cancer or inflammatory bowel disease and a family history of colorectal cancer, adenomatous polyps, familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer. A positive result from a previous noninvasive biomarker screening test also falls outside the asymptomatic criterion. Patients must receive counseling on test performance and the importance of follow-on colonoscopy after a positive result.

The test must have FDA marketing authorization with a colorectal screening indication, meet required FDA postapproval-study conditions for continued coverage, and be processed in a CLIA-certified laboratory. Its FDA-labeled performance against the recognized standard must meet either sensitivity of at least 90% with specificity of at least 87%, or sensitivity of at least 79% with specificity of at least 90%. Other indications not otherwise specified in the Act, regulations or the NCD remain nationally noncovered. The claims instructions identify ColoSense code 0421U and waive its deductible and coinsurance when the NCD criteria are met. Frequency edits require at least 35 months since the last covered screening, implementing the three-year interval. Contractors will not search their files for affected June 8 onward claims, but may adjust claims brought to their attention; the January systems date therefore does not promise automatic retrospective payment.

Why it matters

Ordering eligibility, laboratory/test qualification and claims edits must agree. Treating the January systems date as the start of coverage, or promising waived cost sharing without the NCD criteria, can misdirect patients and billing staff.

Response type

Implement

Confidence

High

Who this affects

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Coding

Affected functions

Coding, Revenue Cycle, Clinical Operations, IT, Quality

What to do nextHave clinical and coding owners verify patient risk, symptoms, counseling, test eligibility and the screening interval. Align 0421U cost-sharing logic with the NCD, track January 4 implementation, and refer potentially affected June 8 onward claims to the MAC for possible adjustment without assuming an automatic search or guaranteed adjustment.

Permalink: #ncd-210-3-colorectal-cancer-non-invasive-biomarker-tests · Development ID GC-2026-0013