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OIG did not pick Methodist Hospital at random: computer matching and data mining flagged its heavy concentration of claims in known billing-error risk areas. Auditors pulled 100 inpatient and outpatient claims, found 27 that fell short of Medicare billing requirements, and extrapolated $256,926 in sample overpayments into at least $12.4 million across a $62 million frame (Butler Snow's analysis,). The hospital disputed the inpatient-rehab findings and the extrapolation itself

CMS has selected H1 to supply the ground-truth data work behind its National Provider Directory, the federal attempt at one trusted, reconciled source of provider information. H1 will source and license authoritative records, then normalize, validate, enrich, and correct them. The payoff: more than 2 million providers keeping accurate listings, over 100 million Medicare and Medicaid beneficiaries finding the right clinician at the right location, and fewer ghost networks in p

If no deal lands by September 30, USA Health's two Mobile hospitals go out of network for UnitedHealthcare commercial and Medicare Advantage members on October 1. The grievance is seven years of flat rates, and the lever is USA Health's claim that UHC denies 325 percent more than competing insurers do, a figure Live Insurance News notes is unverified. These are the region's only Level I trauma center and its only Level III NICU.

On September 24, Ensemble announced it would embed Penelope Health's payer policy platform into the revenue cycle work it does for hospitals nationwide. The draw is coverage rules as structured data, spanning more than 200 million Americans, surfaced before care is delivered rather than after the denial. Ensemble frames that sequencing as fewer denials, faster authorizations and stronger appeals.

Elevance will validate reported locations against hospital addresses and pay based on where care was actually delivered, a policy Axios first reported Tuesday, rolling out across 2026 and 2027. The target is off-campus facilities billed at in-hospital rates, where a 2023 Blue Cross Blue Shield Association analysis put Medicare's three-year overpayment for four services at $2.7 billion. Congress's own fix, unique billing identifiers for off-campus sites, takes effect in 2028.

Black Book polled 74 MGMA conference attendees about their 2027 planning, and the money worries ran the table. Nearly all report operating costs already running above 2025, led by staffing, benefits, and supplies. Black Book lists the likely responses as closer payer-contract scrutiny, stronger denial prevention, and selective outsourcing.

Tomorrow New York's ABA technician rate becomes the lowest published Medicaid rate in the country: $9.63 per 15-minute unit, half what it paid a year ago. A preliminary joint survey suggests almost every enrolled Medicaid provider may exit; one Utica practice has told families that today, September 30, is its final day of ABA services.

Lakeland Regional Health reached a new three-year agreement with UnitedHealthcare on September 29, so Commercial, Medicare, and Medicaid members stay in network through September 30, 2029, with no interruption. It closed one day before the old contracts began expiring: commercial and employer-sponsored members would have gone out of network October 1, Medicare Advantage on January 1, 2027.

Ohio would move Medicaid behavioral-health coverage limits off the rulebook and onto a website master list it could change without formal rulemaking. Same-day IOP and PHP billing for adults would be barred, and group therapeutic behavioral services capped at 10.5 hours a week. Shumaker, Loop & Kendrick notes the drafts are not formally filed yet, so public comment can still shape them.

Since January 1, CMS-0057-F has required Medicare Advantage and Medicaid/CHIP plans to decide standard requests within seven calendar days and urgent ones within 72 hours, with a specific reason for denials. The lever is documentation: a provable submission timestamp for every request and a per-payer definition of late that accounts for extensions. Match those auth records against claims data and a late response becomes a dated pattern you can press, not a complaint about bei