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 on August 28, 2026 that it stopped more than $1.6 billion in potentially improper Medicare laboratory payments. The agency described deploying advanced analytics, including artificial intelligence and machine learning models, against Medicare fee for service claims to flag unusual billing before payment. The $1.6 billion is an aggregate of four different categories rather than a single pool of blocked payments, and CMS states each one differently: $732 million in savings from the revocation of 157 laboratory providers, more than $500 million in potentially fraudulent payments halted through 185 payment suspensions arising from a CMS investigation of 600 laboratories, more than $276 million recouped from 442 identified overpayments already paid out, and $127 million in potentially fraudulent payments prevented as a result of 85 law enforcement referrals. Only the $276 million describes money recovered after it was paid. The remainder combines projected savings from enrollment revocations, payments held under suspension, and payments CMS reports as prevented. CMS uses the words potentially improper and potentially fraudulent throughout the body of the release, while its own headline reads fraudulent, and the release reports no adjudication of fraud behind these amounts. CMS gave three case examples: one individual who enrolled 14 laboratories in Medicare fee for service and billed more than $24 million for services that could not have been rendered, with $12 million currently held by suspension, and two Texas laboratories that began billing at the end of February 2026 and in May 2026 and drew claim denials of $1.2 million and $1.9 million. The release named pathogen detection, high complexity drug testing and genetic testing as the areas of suspicious activity, and it does not direct providers to take any action.

Why it matters

CMS imposed no obligation here, so the value of the announcement is what it says about the instruments in use and how fast they move. Three of the four categories interrupt cash before any appeal: prepayment denial, payment suspension, and enrollment revocation. Each attaches to a billing national provider identifier, so a hospital outreach laboratory, a wholly owned reference laboratory, or a laboratory joint venture can carry the exposure even when the hospital itself is not the target. The named categories, pathogen detection, high complexity drug testing and genetic testing, are where hospital laboratory volume ramps quickly and where medical necessity documentation is thinnest. In the two Texas examples the interval from the start of the billing pattern to denials was a matter of months, which is faster than most internal monitoring cycles. The aggregate itself should be read with care: it mixes projected savings, held payments and actual recoupments, and CMS characterizes the underlying billing as potentially improper rather than as adjudicated fraud.

Response type

Validate

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

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

Recommended actionThis is a self directed review, not an agency requirement, and nothing in the CMS release mandates it. Run a claims level review of the organization's laboratory billing in the three named categories for the last twelve months, look for month over month volume steps, and confirm that an ordering provider relationship and a medical necessity record exist for each sampled claim. Confirm that the enrollment record for every laboratory billing identifier the organization controls, including joint ventures and managed laboratories, is accurate and that someone owns revalidation. Put the result in front of the compliance committee with the volume trend attached.

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 posted on August 27, 2026 that two MolDX local coverage determinations are finalized for Jurisdiction E, which covers California, Hawaii, Nevada and the Pacific territories, effective October 12, 2026. They are L40242, MolDX: Genetic Testing for Hereditary Thrombophilia, and L40222, MolDX: Non-Next Generation Sequencing Targeted Molecular Panel Tests for Targeted Therapy in Cancer. The associated billing and coding articles are A60272 and A60239. Separately, Noridian posted that L36155, MolDX: Genetic Testing for Hypercoagulability and Thrombophilia covering Factor V Leiden, Factor II Prothrombin and MTHFR, retires effective October 11, 2026, one day before the replacement policy takes effect.

Why it matters

This is the California Medicare Administrative Contractor changing what it will and will not cover for two families of molecular tests that hospital laboratories and oncology services order regularly. A retirement and a replacement on consecutive days means the coverage basis for a thrombophilia test ordered on October 11 is different from one ordered on October 12, and any order set, laboratory compendium entry, or medical necessity screen built against L36155 stops matching the policy. Non next generation sequencing targeted panels in oncology are the second exposure, since a panel ordered outside the finalized indications becomes a denial rather than a coverage question after the effective date.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal, California, Hawaii, Nevada

Primary owner

Coding

Affected functions

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

Recommended actionRead L40242, L40222 and the billing and coding articles A60272 and A60239 before October 12, 2026. Map the organization current thrombophilia and targeted panel test menu to the finalized indications, update the laboratory compendium, order sets and medical necessity screening logic, and brief the ordering services. Where a test the organization performs or sends out is no longer covered, decide and document the advance beneficiary notice position before the effective date.

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 published a notice on August 27, 2026 proposing a new information collection, CMS-10971, the Acute Hospital Care at Home Quantity, Intensity, and Mix of Services data collection tool. Participating hospitals would report annually on the number of clinician visits, food services, and pharmacy services provided to patients in the hospital at home setting. CMS estimates roughly 365 responding hospitals, 13,000 total annual responses, and 13,000 hours of reporting burden. The collection stems from the Consolidated Appropriations Act, 2026, which directs CMS to evaluate care quality and service delivery patterns in hospital at home, and the data is intended for congressional reporting. Comments are due October 26, 2026.

Why it matters

For a hospital in the Acute Hospital Care at Home initiative this is a new annual data obligation with three counts that most programs do not capture as structured fields today: clinician visits, food services, and pharmacy services delivered in the home. Whether those counts can be produced from existing documentation, or require a workflow change, is a question to answer during the comment period rather than after the collection is approved. For a hospital considering the waiver, the reporting burden is now part of the business case.

Response type

Comment

Confidence

High

Applies to

Health systems

Jurisdiction

Federal

Primary owner

Clinical Operations

Affected functions

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

Recommended actionConfirm whether the organization participates in the Acute Hospital Care at Home initiative. If it does, ask the program owner whether clinician visit, food service, and pharmacy service counts can be produced from current documentation, name a data owner for each of the three counts, and decide by October 26, 2026 whether to comment on the burden estimate.

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 published a Medi-Cal provider notice on August 26, 2026 stating that action must be taken to confirm the accuracy of the Public Fee-For-Service Provider Directory quarterly, in accordance with Section 5123 of the Consolidated Appropriations Act, 2023. Beginning October 1, 2026, Provider Portal administrators must complete all of the survey questions in the Provider Portal Directory within 45 days. In each quarter following, providers must update or validate that the provider directory information is accurate within 45 days. Administrators must indicate whether each service location under their organization is accepting new fee for service patients, managed care patients, or both, and must save the directory after reviewing and answering all survey questions. DHCS states that failure to complete the required quarterly updates will result in all users within the organization losing access to the Provider Portal Transaction Center, and that a user who loses access should contact their Provider Portal administrator to update the directory and restore it. The notice states that the 45 day window opens on October 1, 2026 and does not state a calendar end date for it.

Why it matters

The consequence is disproportionate to the task and lands on the wrong people. One administrator failing to answer a survey removes Provider Portal Transaction Center access for every user in the organization, which is an eligibility, claims and transaction outage rather than a directory problem. The obligation recurs every quarter, so it needs a calendared owner and a named backup rather than a one time assignment, and organizations with many service locations have to answer the accepting new patients question accurately for each one, which is a data question the enrollment team may not own today.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

California

Primary owner

Provider Enrollment

Affected functions

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

Recommended actionIdentify every Medi-Cal Provider Portal administrator the organization has and confirm each one knows the obligation starts October 1, 2026. Name a primary and a backup owner per organization identifier, and put the validation on a recurring quarterly calendar rather than treating it as a single task. Before the first submission, confirm with patient access and the service line owners whether each service location is in fact accepting new fee for service patients, managed care patients, or neither, so the directory answer matches practice. Confirm the escalation path if Transaction Center access is lost, since restoring it depends on the administrator completing the directory.

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 2026 Medicare claims processing updates: laboratory fee schedule and CLIA on October 1, electronic data interchange and physician fee schedule database on October 5

What changed

Two of the transmittals CMS issued on August 27, 2026 implement on October 5, 2026: R13934OTN with change request 14429, HIPAA electronic data interchange front end updates for October 2026, and R13929CP with change request 14588, the quarterly update to the Medicare Physician Fee Schedule Database for October 2026. The MLN Connects edition of August 27, 2026 separately carried two items effective earlier in the month: the October 2026 clinical laboratory fee schedule and Clinical Laboratory Improvement Amendments quarterly update, effective October 1, 2026, covering annual and quarterly CLIA edits, new waived test updates, and new and deleted CPT codes; and the October 2026 home health prospective payment system grouper, version 07.2.26, released August 20, 2026. The earliest of these dates is October 1, 2026 and the latest is October 5, 2026.

Why it matters

None of these change a compliance obligation on their own, but each lands in a claims or grouper system on a fixed date, and a missed update shows up as a denial or an underpayment rather than as an error message. Two different dates in the same month is the practical risk here: a release plan built only around October 5 misses the laboratory fee schedule and CLIA edits that take effect on October 1. The clinical laboratory fee schedule and CLIA quarterly update matters more than usual this quarter given the CMS laboratory program integrity actions carried as a P1 in this issue.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, IT, Coding, Finance

Recommended actionConfirm with the claims system owner that the October 1, 2026 clinical laboratory fee schedule and CLIA quarterly update and the October 5, 2026 electronic data interchange and physician fee schedule database updates are each scheduled, and confirm with the home health application owner that the version 07.2.26 grouper download is assigned. Ask for written confirmation after each release rather than assuming it applied. The January 4, 2027 items from the same August 27, 2026 transmittal set are tracked separately and need their own owner.

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

January 2027 Medicare updates: HCPCS quarterly file download instructions and the annual clotting factor furnishing fee, both implementing January 4, 2027

What changed

Two of the transmittals CMS issued on August 27, 2026 implement on January 4, 2027 rather than in October. R13938CP, change request 14586, gives instructions for downloading the Healthcare Common Procedure Coding System files for the January, April, July and October 2027 quarterly releases, with an effective and implementation date of January 4, 2027. R13937CP, change request 14580, is the annual clotting factor furnishing fee update for 2027, also implementing January 4, 2027.

Why it matters

Both items were issued in the same August 27, 2026 batch as the October 2026 claims processing updates but land a full quarter later, which is how a January item gets absorbed into an October release plan and then missed. The HCPCS download instruction governs how the coding files underneath the 2027 quarterly releases are obtained, so an unassigned owner shows up as a stale code file in January rather than as a failure at the time. The clotting factor furnishing fee is a pricing update that reaches reimbursement for hemophilia products directly.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Revenue Cycle

Affected functions

Revenue Cycle, IT, Coding, Finance

Recommended actionName an owner now for each of the two January 4, 2027 items and put them on the January release calendar rather than the October one. For R13938CP, confirm that whoever loads the quarterly HCPCS files has the 2027 download instructions and a scheduled task for each quarterly release. For R13937CP, confirm that the clotting factor furnishing fee is updated in the pricing file for dates of service on and after the implementation date, and that pharmacy and revenue cycle both know when it changes.

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

New national coverage determination for non invasive colorectal cancer biomarker screening tests, implementation January 4, 2027

What changed

CMS issued transmittals R13921NCD and R13921CP on August 27, 2026 under change request 14581, implementing national coverage determination 210.3, Screening for Colorectal Cancer, for non invasive biomarker tests. The implementation date is January 4, 2027. Noridian and the MLN Connects edition of August 27, 2026 also carried the related ICD-10 and other coding revisions to national coverage determinations, January 2027 update, part 2 of 2, effective January 1, 2027.

Why it matters

A national coverage determination sets the coverage floor for every Medicare Administrative Contractor, so this reaches the colorectal cancer screening order sets, the preventive services logic, and the patient cost sharing message. Screening services carry a cost sharing waiver when the coverage criteria are met and a patient bill when they are not, so the coding revisions effective January 1, 2027 and the transmittal implementation on January 4, 2027 need to be applied together.

Response type

Implement

Confidence

High

Applies to

Health systems, Provider networks

Jurisdiction

Federal

Primary owner

Coding

Affected functions

Coding, Revenue Cycle, Clinical Operations, IT, Quality

Recommended actionAssign an owner now for the January 2027 implementation. Read NCD 210.3 as implemented by change request 14581, confirm which non invasive biomarker tests the organization offers or sends out fall inside it, and align the screening order sets, preventive services logic and cost sharing messaging with the January 1, 2027 coding revisions.

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