Literature Review

False Claims Act 2025 year-end update Gibson, Dunn & Crutcher; Press Release; 1/27/26 This update covers recent developments in FCA jurisprudence, summarizes significant enforcement activity, and analyzes the most notable legislative, policy, and caselaw developments from the second half of calendar year 2025, picking up where our mid-year 2025 update left off.

MedPAC signals need to bolster Medicare physician payments AMA - American Medical Association; by Tanya Albert Henry; 1/27/26 Influential body backs added 0.5% Medicare pay update but backtracks on linking doctor payment to practice-cost inflation. ... The influential Medicare Payment Advisory Commission (MedPAC) voted in January to address inadequate payment for Medicare physician services under current law, once again underscoring a longstanding policy failure that is widely recognized but remains unresolved. MedPAC voted to recommend an additional 0.5% update on top of the updates specified in current law—0.25% and 0.75%—and will forward that recommendation to Congress. 

HHS-OIG Semiannual Report to Congress: April 1 - September 30, 2025 HHS Office of Inspector General; by the OIG; 1/21/26 OIG publishes the Fall 2025 Semiannual Report to Congress. Also posts two enforcement actions.Fall 2025 Semiannual Report to Congress Today, OIG released its Fall 2025 Semiannual Report to Congress, summarizing its activities and accomplishments from April 1, 2025, through September 30, 2025. The report outlines OIG’s work to address fraud, waste, abuse and mismanagement across HHS programs—and driving change through oversight and accountability. OIG's efforts during this period led to a total monetary impact of $2.43 billion, demonstrating the agency’s role in protecting taxpayer funds and improving program performance. Read the full report now to understand how OIG is working to safeguard taxpayer dollars and enhance government performance. 

Update your HIPAA Notice of Privacy Practices by February 16, 2026 The National Law Review; by John D. Arendshorst , Charles M. Russman, Carolyn M. H. Sullivan, Kristy L. De Vos, Varnum LLP; 1/21/26 Whether your company provides health benefits or qualifies as a covered entity under the Health Insurance Portability and Accountability Act (HIPAA), it is important to update your Notice of Privacy Practices (NPP) by February 16, 2026, to remain HIPAA compliant. The updated requirements focus on how substance use disorder information may be used or disclosed and remove reproductive health language that was previously added but has since been revoked. ... [Additionally]:

Medicare Advantage overpayments will total $76B this year: MedPAC Healthcare Dive; by Rebecca Pifer Parduhn; 1/16/26 The federal government will pay an estimated $76 billion more to cover Medicare Advantage seniors this year than it would if those same seniors were in traditional Medicare, according to new estimates from an influential advisory group. ... Still, the report released [1/16] Friday by the Medicare Payment Advisory Commission is likely to add more fuel to concerns about overpayments in the privatized Medicare program, which has grown to cover more than half of all Medicare enrollees.

Increased criminal and civil enforcement by DOJ for skin substitutes in wound care JD Supra; by Tanisha Palvia, Jenn Sugar, Moore & Van Allen PLLC; 1/15/26 The Department of Justice recently announced, “[i]n the first [criminal] prosecution of its kind,” that husband and wife owners of wound graft companies were sentenced to 14.5 and 15 years imprisonment respectively for causing over $1.2 billion in false claims to be submitted to Medicare Part B and other federal health care programs for medically unnecessary wound grafts. ... The massive scheme had medically untrained sales representatives find elderly Medicare beneficiaries, often in hospice care, with any kind of wound.

US health expenditures rapidly accelerating Hospice News; by Jim Parker; 1/14/26 ... Rising health care utilization is the most significant driver of the spending increases, according to CMS. One key factor is that utilization is bouncing back from declines that occurred during the COVID-19 pandemic, according to Micah Hartman, a statistician in the National Health Statistics Group with the Office of the Actuary at CMS. Population growth was also a factor. ... By payer type, private health insurance saw the largest rate of spending growth at 8.8%, followed by Medicare at 7.8% and Medicaid at 6.6%. Out-of-pocket spending rose by 5.9%. ... Hospice care saves Medicare roughly $3.5 billion for patients in their last year of life, according to a joint report from the National Hospice and Palliative Care Organization (NHPCO), the National Association for Home Care & Hospice (NAHC) and NORC at the University of Chicago.

CMS, hospice groups mull Wage Index reform Hospice News; by Jim Parker; 1/13/26 Some stakeholders in the hospice space are seeking reforms to the hospice wage index. ... CMS has given indications that it would mull changes to the hospice wage index. In 2025, the agency convened a technical expert panel to consider the issue. One point of discussion is the application of new data sources, including potential changes to hospice cost reports. ... One proposal discussed within the panel would be to revise the hospice cost report to collect accurate information about costs related to full-time employees, ... To implement a new wage index methodology, CMS would also have to go through a proposed rulemaking process, including public notice and a comment period. With any wage index changes, some hospices would “win” and others would “lose.” Some providers may see higher payments as a result, whereas others may see their rates go down. ...

CMS releases RFI to overhaul Medicare claims system Inside Health Policy; by Jalen Brown; 1/9/26 CMS unveiled a request for information (RFI) Thursday (Jan. 8) aimed at replacing Medicare’s decades-old claims processing system with a modern, cloud-based platform that would be capable of adjudicating millions of claims per day in real time, which would fundamentally re-architect how Medicare pays providers. In Thursday’s RFI, dubbed “ClaimsCore,” CMS is asking large-scale technology vendors to demonstrate whether they can operate a full Medicare claims adjudication system inside a CMS-owned Amazon Web Services cloud environment.

In or out: The hospice, Medicare Advantage conundrum Hospice News; by Jim Parker; 1/2/26 Opposition to a Medicare Advantage hospice “carve-in” remains strong in the field, though some say the lack of one creates a serious gap in the MA program. Medicare Advantage enrollment continues to grow. As of 2025, 54% of Medicare beneficiaries were enrolled in Medicare Advantage, about 31.4 million people, according to the Kaiser Family Foundation. However, MA health plans, by design, do not cover hospice care. When an MA beneficiary elects hospice, they transition to the traditional Medicare benefit, though they may keep their Medicare Advantage coverage for care or services deemed unrelated to their terminal condition.

Hospice care for medicaid cancer patients in Puerto Rico: implications on healthcare costs and utilization JNCI Cancer Spectrum; by Karen J Ortiz-Ortiz, Marjorie Vázquez-Roldán, Axel Gierbolini-Bermúdez, María Ramos-Fernández, Carlos R Torres-Cintrón, Yisel Pagán-Santana, Tonatiuh Suárez-Ramos, Kalyani Sonawane; 12/27/25 Online ahead of print Background: ... In Puerto Rico, Medicaid had no provisions for hospice care until July 2024, representing a significant public health challenge. This study examined the association between hospice coverage policy and EoL outcomes among patients with cancer enrolled in Medicaid.Conclusion: Hospice enrollment among Medicaid enrollees was associated with lower health expenditure, lower healthcare resource utilization, and a lower likelihood of mortality in an acute setting. The recent policy change to include hospice services coverage in Puerto Rico Medicaid is a positive step that must be sustained beyond 2027.

Medicaid agencies made millions in unallowable capitation payments to managed care organizations on behalf of deceased enrolleesOIG press release; 12/23/25A new OIG audit found that from July 2021 to June 2022, state Medicaid programs made an estimated $207.5 million in capitation payments to managed care organizations for enrollees who were already deceased. This estimate is based on the results of our review of 100 statistically sampled capitation payments. We determined that Medicaid agencies made unallowable capitation payments after enrollees’ deaths for 99 of the 100 sample capitation payments.

Long-term hospice stay: New edit to prevent overpayment CMS - MLN Matters - Medicare Learning Network; by the U.S. Department of Health & Human Services; 12/5/25Related CR Release Date: December 5, 2025Effective Date: April 1, 2026Implementation Date: April 6, 2026Action Needed: Make sure your billing staff knows about a new edit that will help identify and prevent overpayments of long-term hospice care for claims submitted with matching “admission” and “from” dates.Key Updates: This new edit in the CWF will close the gap in the system that allows claims to pay at a higher rate when the “admission” and “from” dates match. MACs will reject hospice claims when the “admission” date doesn’t match the election period start date on the corresponding election period. ...