DOJ Settlement Over MA Coding
Monogram Health settled with the Department of Justice over allegations around diagnosis data submitted for Medicare Advantage beneficiaries. DOJ specifically cited issues with HCCs involving protein-calorie malnutrition, substance use disorder, coagulation disorders and angina. The DOJ has stated it plans to continue investing resources in uncovering potential coding practices by MA issuers, vendors, and providers.
Potential California Changes
The state of California is considering levying penalties on hospitals and insurers if they don’t meet state spending limits. The Office of Health Care Affordability may adopt penalties as much as 125% of the total they spend above the state’s annual growth targets (it will be 3.5% in 2026 and 3% starting in 2029). The soonest health care entities could face a penalty would be in 2028 because the data to measure 2026 performance would not be available until then.
No Surprises Act Analysis
New analysis estimates that the No Surprises Act contributed to an estimated $22.4 billion in total cost. The No Surprises Act was passed to protect patients from surprise bills and create a dispute resolution program to adjudicate the surprise bills between providers and payers. The process is used far more often and has been more expensive than expected. For example, in 2025, total costs were $16.6 billion, about 3.5 times larger than 2024. Providers are winning about 85% of the disputes.
2027 Watch
STAT News ($) reported that Democrats were discussing how they would roll back Medicaid cuts should they retake Congress in 2027. Senate Minority Leader Chuck Schummer said he would give hospitals a seat at the table in formulating next steps for policy.
