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105 published findings

Billing fraud & false claimsEnforcement BriefingContinuing

The Villages Health System agrees to a $541.5 million settlement over invalid Medicare Advantage diagnosis codes after self disclosing

A $541.5 million settlement addresses allegedly unsupported Medicare Advantage diagnoses and chart amendments at The Villages Health System. DOJ credited self-disclosure and cooperation. Bankruptcy approval and the plans’ separate repayment responses are part of the resolution; liability was not determined.

High priority · Sep 20, 2026 editionRead story →

Audits & program integrityMedicare & MedicaidContinuing

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

CMS’s August 28 laboratory announcement combines projected savings, suspended payments, recoupments and referral-related prevention. Its examples describe rapid billing intervention, but the headline total is not a single recovered sum or an adjudication that every associated claim was fraudulent.

High priority · Sep 20, 2026 editionRead story →

Billing fraud & false claimsEnforcement BriefingContinuing

Monogram Health agrees to $2.4 million settlement over Medicare Advantage diagnosis codes

Monogram’s $2.4 million resolution concerns four diagnosis categories submitted under in-home Medicare Advantage risk-sharing arrangements. DOJ describes clinical accuracy, documentation and relevance to care during 2021–2023, credits cooperation and provides a whistleblower share. The allegations were not adjudicated.

Medium priority · Sep 20, 2026 editionRead story →

Consumer & business misconductEnforcement BriefingContinuing

Walmart agrees to $50 million opioid-prescription settlement and dispensing safeguards

The $50 million resolution addresses alleged unlawful dispensing despite prescriber and prescription warning signs. A DEA agreement adds employee/patient reporting, pharmacy-pattern monitoring and suspect-prescriber review. The dated August 28 announcement reports allegations, not a determination of liability.

Medium priority · Sep 20, 2026 editionRead story →

Billing & paymentMedicare & MedicaidContinuing

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

DHCS’s August 26 notice requires quarterly validation of the public fee-for-service provider directory starting October 1. Administrators have a forty-five-day window and must save completed survey responses; missed updates affect every user’s Transaction Center access in the organization.

Medium priority · Sep 20, 2026 editionRead story →

Consumer & business misconductEnforcement BriefingContinuing

CDPH issues ten California facility citations and penalties totaling $73,750, including two class A citations

Ten CDPH records carry August 26–27 issue dates and $73,750 in initial assessments across eight facilities. The data identify two class A citations, seven class B citations and one administrative penalty. They do not establish collections, completed appeals or a full account of the underlying incidents.

Medium priority · Sep 20, 2026 editionRead story →

Governance & business operationsCompliance SweepContinuing

AB-173 Health

AB 173’s September 18 enactment changes the Medi-Cal affiliation-risk framework, subject to federal implementation conditions.

Medium priority · Sep 20, 2026 editionRead story →

Medi-Cal & Medicaid policyMedicare & MedicaidContinuing

AB-220 Medi-Cal: subacute care services

Pending AB 220 would limit extra pediatric subacute criteria and duplicate authorization forms, with specific protections for return from an acute-hospital bed hold.

Medium priority · Sep 20, 2026 editionRead story →

Coverage & clinical policyMedicare & MedicaidContinuing

AB-280 Health care coverage: provider directories

Pending AB 280 proposes a central provider-directory utility, common standards and reasonable-reliance protections, with specific integrated-plan and Medi-Cal scope exceptions.

Medium priority · Sep 20, 2026 editionRead story →

Coverage & clinical policyMedicare & MedicaidContinuing

AB-350 Health care coverage: fluoride treatments

Pending AB 350 addresses medically necessary fluoride varnish across medical and dental billing and proposes Medi-Cal guidance for members under twenty-one, with training and federal conditions.

Medium priority · Sep 20, 2026 editionRead story →

AI & digital healthCompliance SweepContinuing

AB-1018 Automated decision systems

AB 1018 proposed consequential-decision AI controls with important health-sector exclusions and retained notice duties.

Medium priority · Sep 20, 2026 editionRead story →

Coverage & clinical policyMedicare & MedicaidContinuing

AB-1682 Health care coverage: scalp cooling

Pending AB 1682 would cover prescribed FDA-cleared scalp cooling for chemotherapy-related hair loss in large-group coverage and conditionally in Medi-Cal.

Medium priority · Sep 20, 2026 editionRead story →

Coverage & clinical policyMedicare & MedicaidContinuing

AB-1876 Health care coverage: nondiscrimination

Pending AB 1876 would strengthen plan and insurer nondiscrimination provisions and grievance notices while preserving legitimate, nondiscriminatory clinical and coverage decisions.

Medium priority · Sep 20, 2026 editionRead story →

Billing & paymentMedicare & MedicaidContinuing

AB-2499 Health care coverage: claims payments

Pending AB 2499 would require standard electronic supporting-document submission from May 26, 2028, including receipt confirmation and protections against system-only claim delays.

Medium priority · Sep 20, 2026 editionRead story →

Billing & paymentMedicare & MedicaidContinuing

AB-2571 Reimbursement for pharmacist services

Pending AB 2571 would expand pharmacist payment routes and advanced-practitioner reimbursement, with distinct commercial, Medi-Cal and FQHC/RHC conditions.

Medium priority · Sep 20, 2026 editionRead story →

Compliance Sweep: complete report →Enforcement Briefing: complete report →Medicare & Medicaid: complete report →

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