From March 18–20, 2026, the American Health Law Association (AHLA) hosted its annual Institute on Medicare and Medicaid Payment Issues conference in Baltimore, Maryland, focused on the full range of risks and opportunities relating to participation in federal health care payment programs. The schedule provided a formal blueprint for addressing updates in Medicare Parts A & B, Medicaid program changes, supplemental payments, cost reporting, appeals, fraud and abuse, compliance obligations, and health equity requirements. Partners Scott McBride and Greg Etzel made presentations on the underpinnings of overpayments and on Medicare cost reporting and appeals, respectively.
Health Law Scan
Legal Insights and Perspectives for the Healthcare Industry
2025 was an important year for Medicare Advantage (MA) plans that pay state-licensed agents and brokers to market their plans and engage in lead generation, subject to complex federal regulations. As we previously discussed on Health Law Scan, improper broker arrangements were identified as a 2025 focus area by the whistleblower bar and the US Department of Justice (DOJ), particularly the US Attorney’s Office for the District of Massachusetts.
On May 8, 2025, the Boston Bar Association hosted its annual White Collar Crime Conference, a reoccurring theme of which was the recognition of changing times, while also maintaining that the core principles of criminal and civil fraud enforcement remain the same. An anticipated highlight from the conference came from the panel addressing federal and state False Claims Act (FCA) and Anti-Kickback Statute (AKS) enforcement priorities.
The HHS Office of Inspector General (OIG) announced on June 15, 2023 that it plans to initiate a new audit of Medicare payments for hospice general inpatient (GIP) services, focused on hospice GIP services furnished to Medicare beneficiaries who were discharged directly to hospice GIP care from an acute hospital stay.
The US Department of Justice’s (DOJ’s) Civil Division released its annual fraud statistics on February 7, covering fiscal year 2022. Settlements and judgments under the False Claims Act (FCA) exceeded $2.2 billion in the fiscal year ending on September 30, 2022. Consistent with previous years, a significant portion of the recoveries related to the healthcare industry.
The Centers for Medicare & Medicaid Services (CMS) delayed the publication of the final rule on the use of extrapolation and the application of a fee-for-service adjuster (FFS Adjuster) in risk adjustment data validation (RADV) audits of Medicare Advantage organizations (MAOs). The proposed rule was published on November 1, 2018, more than four years ago. With this latest extension, the final rule deadline is now February 1, 2023.
Last month, we had an engaging Fast Break session covering the growing importance of risk adjustment in various health insurance programs and novel government theories of liability associated with risk adjustment reporting. Morgan Lewis associates Tesch Leigh West and Michelle M. Arra described the fundamental processes regarding risk adjustment and highlighted recent audit and enforcement trends in this area.