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Author: Lauren Brown

UAB Expands Access with Planned Freestanding Emergency Department in Oxford

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UAB Health System is continuing its expansion of community-based care with plans to develop a third freestanding emergency department—this time in Oxford, Alabama. The project is currently in the early stages, with a letter of intent submitted to the Alabama State Health Planning and Development Agency to obtain necessary approvals. The proposed facility would be a joint effort between UAB, the city of Oxford, and Oxford Health Systems, reflecting a collaborative approach to addressing growing…
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10 Recent Healthcare Billing Fraud Cases Highlight Ongoing Enforcement Trends

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Recent enforcement activity across the healthcare industry underscores continued scrutiny around billing practices, particularly involving telemedicine, durable medical equipment (DME), and medical necessity. Here’s a high-level look at 10 notable cases reported since early March, ranked by scale and impact: 1. $59.9M Medicare DME Fraud Scheme (Texas)A Texas individual received a lengthy prison sentence for involvement in a massive scheme billing Medicare for medically unnecessary equipment—one of the largest cases in this group. 2. $12.5M…
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CLFS Reporting Requirements Begin May 1: What Labs Need to Know

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Clinical laboratories subject to the Clinical Laboratory Fee Schedule (CLFS) should prepare for the upcoming data reporting period beginning May 1, 2026. This requirement applies to independent labs, physician office labs, and hospital outreach laboratories that meet the criteria of an “applicable laboratory” under federal guidelines. The reporting window runs from May 1 through July 31, 2026, and is based on data collected between January 1 and June 30, 2025. Laboratories will need to submit…
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Study Suggests Methylphenidate May Lower Psychosis Risk in Children with ADHD

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New research highlights important insights into the long-term safety of commonly prescribed ADHD medications. A study published in JAMA Psychiatry found that methylphenidate—widely used in treatments like Ritalin and Concerta—does not increase the risk of psychosis in pediatric patients and may even offer protective benefits when used over time. Researchers analyzed health data from nearly 4,000 children and adolescents diagnosed with ADHD and found no increased risk of psychosis among those treated with methylphenidate compared…
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Louisiana Moves to Rein in AI Use in Coverage Denials

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Louisiana lawmakers are advancing legislation that could significantly change how artificial intelligence is used in payer decision-making—particularly when it comes to denying coverage. The proposed bill would require that any denial involving AI or automated systems be reviewed and approved by a qualified human clinician, ensuring decisions are based on individualized patient circumstances rather than algorithms alone. If enacted, the policy would roll out in phases beginning in August 2026, eventually applying to all new…
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Court Orders UnitedHealth to Release Documents in AI Denial Lawsuit

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A federal judge in Minnesota has ordered UnitedHealth Group to produce extensive documentation in an ongoing lawsuit alleging improper use of AI in Medicare Advantage coverage decisions. The case centers on the use of nH Predict, a tool developed by the company’s Optum division (formerly naviHealth), which plaintiffs claim contributed to premature denials of post-acute care—particularly skilled nursing services. The lawsuit, filed by families of two deceased patients, argues that the tool may have overridden…
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Aetna to Pay $117.7M to Settle Medicare Advantage Coding Allegations

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Aetna has agreed to pay $117.7 million to resolve federal allegations that it improperly inflated Medicare Advantage payments by submitting inaccurate diagnosis codes and failing to correct them when unsupported by medical records. The settlement, brought under the False Claims Act by the U.S. Department of Justice, centers on risk-adjustment practices used to determine payments from the Centers for Medicare & Medicaid Services (CMS). Under this model, insurers receive higher payments for members with more…
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UnitedHealthcare Expands Doula Coverage to Support Maternal Health Outcomes

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UnitedHealthcare has announced a nationwide expansion of doula coverage for eligible employer-sponsored and commercial plans, marking one of the greatest efforts of its kind in the private insurance market. The phased rollout, beginning in 2026, could reach approximately 7.2 million members by January 1, 2027, depending on employer participation. Coverage options may include a set number of doula visits or reimbursement allowances, with services available both in-person and virtually. Members may also have flexibility in…
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Deadline Reminder: ACO Quality Data Submission for 2025 Performance Year

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The Centers for Medicare & Medicaid Services (CMS) is reminding Medicare Shared Savings Program Accountable Care Organizations (ACOs) that the Quality Payment Program (QPP) data submission deadline is quickly approaching. All quality data for the 2025 performance year must be submitted by March 31, 2026, at 8:00 PM ET. ACOs are encouraged to carefully review their submissions for completeness and accuracy prior to the deadline, as changes or corrections will not be allowed once the…
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CMS Updates QPP Resources and Announces Upcoming MIPS Cost Measure Webinars

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The Centers for Medicare & Medicaid Services (CMS) has released updates to key resources within the Quality Payment Program (QPP), while also inviting stakeholders to participate in upcoming discussions future cost measure development under MIPS. CMS recently updated the 2026 Qualified Clinical Data Registry (QCDR) and the 2025–2026 Qualified Registry postings, reflecting changes such as remedial actions and terminations affecting certain third-party intermediaries. Providers and organizations are encouraged to review the latest versions—along with the…
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3 Emerging Trends Adding Pressure on Anesthesiology Teams

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Recent research is highlighting several growing challenges for anesthesiologists, from evolving patient needs to workforce instability—trends that could impact both clinical care and operations. Together, these trends reflect increasing pressure on anesthesiology teams, emphasizing the need for improved workflows, stronger collaboration, and proactive workforce planning. Resource: 3 studies scaring anesthesiologists

Audit Finds Potential Medicare Advantage Overpayments for BCBS Alabama

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A recent audit from the HHS Office of Inspector General (OIG) estimates that Blue Cross Blue Shield of Alabama may have received at least $7 million in Medicare Advantage overpayments. The findings are based on a review of 271 enrollee-years, where the majority showed discrepancies between submitted diagnosis codes and supporting medical records. These inconsistencies led to approximately $769,000 in identified overpayments within the sample, which OIG used to project the larger total. The audit…
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