CMS Continues DME Anti-Fraud Push
CMS announced it would block 11 medical supply companies from receiving payments under Medicare Advantage or Part D. The firms were involved in $3.4 billion in suspected fraudulent billing practices in 2025 and 2026. The focus on DME billing practices is expected to continue. MA actuaries may need to reassess DME trend baselines.
Congress Lame Duck Session
Modern Healthcare ($) has a nice summary of outstanding (i.e., potential) health care items to be discussed at the end of the year. These include changes to Medicare physician reimbursement, prior authorization rules for Medicare Advantage, transparency measures, and potential anti-fraud measures.
Data You Can Use
Researchers at Yale put together a good summary of price increases in the commercial market and how increases in claims are the overwhelming driver. The researchers estimated that growth in health spending explained 91% of premium growth in the commercial market between 2011 and 2024.
Louisiana v. FDA
Louisiana argued before The Fifth Circuit Court of Appeals that the FDA rules on telehealth prescriptions of the abortion drug mifepristone infringe on Louisiana’s rights. Pharmaceutical and biotech companies filed an amicus brief arguing that the ruling could have broader implications because it could allow any state to ban specific drugs or biotech from their state.
