The Centers for Medicare & Medicaid Services (CMS) has been using prior authorization for selected Hospital Outpatient Department (OPD) services for several years as part of its broader effort to curb improper payments and unnecessary utilization. In late 2025, CMS expanded that approach into the Ambulatory Surgical Center (ASC) setting through a new Prior Authorization
CMS Finalizes Rule Closing Medicaid Provider Tax Loophole
The Centers for Medicare & Medicaid Services (CMS) has finalized a major Medicaid financing rule aimed at closing what the agency has described as a long-standing “healthcare-related tax loophole.” The rule, finalized on January 29, 2026, implements statutory changes enacted last summer and significantly restricts how states
2026 Medicare Physician Fee Schedule
The final Medicare Physician Fee Schedule for 2026 has now taken effect. Under the new rule, Center for Medicare Services (CMS) finalized two separate Medicare conversion factors depending on participation in a qualifying Alternative Payment Model (APM). For physicians who do not qualify as APM participants, the 2026 conversion factor is $33.4009, representing a 3.26%
What the Government Shutdown Means for Physicians
As of October 1st, the federal government is officially shut down after Congress failed to pass funding legislation. While the biggest direct impact will certainly be on furloughed federal workers and government agencies, if your practice relies on Medicare or Medicaid, or you are involved in research, there are ripple effects worth understanding.
What Stays
CMS Unveils 2026 Physician Fee Schedule Proposal: Key Changes Ahead
On July 14, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the 2026 Physician Fee Schedule. As expected, there are several meaningful updates that providers, practices, and health systems should be aware of.
One of the more significant changes is that CMS will split the conversion factor into two separate
DOJ and HHS Launch New False Claims Act Working Group to Target Healthcare Fraud
The U.S. Department of Health and Human Services (HHS) and the Department of Justice (DOJ) have jointly announced the launch of a reinvigorated DOJ-HHS False Claims Act Working Group aimed at enhancing interagency coordination around key fraud enforcement priorities in the healthcare space. This initiative underscores the federal government’s ongoing reliance on the False Claims
New CMS Model Targets Inefficient Medicare Spending Through AI and Clinical Oversight
The Centers for Medicare & Medicaid Services (CMS) has launched the WISeR Model (Wasteful and Inappropriate Service Reduction) to modernize and streamline Medicare’s prior authorization process. By partnering with tech companies, CMS will test the use of modern tools, such as artificial intelligence, to reduce unnecessary or low-value services that drive up costs and pose
DOJ Announces Largest Health Care Fraud Takedown in U.S. History
In the largest health care fraud takedown in U.S. history, the Justice Department announced charges against 324 individuals—including 96 licensed medical professionals—in connection with schemes involving over $14.6 billion in intended losses across 50 federal districts and 12 State Attorneys General Offices. The coordinated enforcement action led to the seizure of more than $245 million
2025 Medicare Final Rule Highlights
Attorneys Mike Cassidy and Adam Appleberry co-authored an insightful article, 2025 Medicare Final Rule Highlights, featured in the December 2024 issue of the Allegheny County Medical Society (ACMS) Bulletin. The article explores the key updates to Medicare regulations and their implications for healthcare providers.
Click here to access the ACMS Bulletin to read
Medicare Telehealth Reimbursement Update
Our Introduction to Telehealth, Technology and Federal Enforcement chapter was published in the Thomson Reuters 2025 Health Law Handbook. It reviewed a number of telehealth Medicare revisions, both permanent and temporary, enacted by a series of consolidated appropriation acts and physician fee schedule amendments arising out of the 2020 COVID pandemic.
The temporary telehealth