April 3, 2026

Major Government Updates from AHLA Medicare and Medicaid Conference

Gregory Etzel, B. Scott McBride, Tesch Leigh West Morgan Lewis - Health Law Scan + Follow Contact LinkedIn Facebook X Send Embed

From March 18–20, 2026, the American Health Law Association (AHLA) hosted its annual Institute on Medicare and Medicaid Payment Issues conference in Baltimore, Maryland, focused on the full range of risks and opportunities relating to participation in federal health care payment programs. The schedule provided a formal blueprint for addressing updates in Medicare Parts A & B, Medicaid program changes, supplemental payments, cost reporting, appeals, fraud and abuse, compliance obligations, and health equity requirements. Partners Scott McBride and Greg Etzel made presentations on the underpinnings of overpayments and on Medicare cost reporting and appeals, respectively.

The government made announcements related to various tech-driven outlier detection initiatives that will be aggressively used to “proactively” and “preemptively” prevent fraud. Providers with legitimate outlier claims data may suffer significant fallout as a result of the government’s approach, which appears to be to suspend payment first and investigate later.

Enforcement Priorities

Unlike last year, this year’s conference included direct engagement with government representatives from the Centers for Medicare and Medicaid Services (CMS), the US Department of Health and Human Services (HHS) Office of Inspector General (OIG), and the HHS Office of General Counsel (OGC). Each agency made a presentation on updates.

OGC Deputy General Counsel Elizabeth Kelley, who also serves as the chief legal officer for CMS, foreshadowed the government’s focus on drug pricing initiatives to lower prices through most-favored nation agreements and Center for Medicare and Medicaid Innovation drug pricing models. She also asked stakeholders for comments on CMS’s Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) rule, which subsequently closed on March 30, 2026. The CRUSH initiative is designed to preemptively guard against potential fraud in government healthcare programs. Ms. Kelley showcased government fraud and abuse enforcement actions related to organ procurement and CMS’s announcement of the awards allocating $50 billion for fiscal years 2026–2030 under the Rural Health Transformation Program.

OIG Chief Counsel to the Inspector General Susan Edwards gave a brief enforcement update and, unsurprisingly, announced that healthcare fraud remains a top federal priority. She touted the US Department of Justice’s (DOJ’s) False Claims Act (FCA) settlements and judgments that exceeded $6.8 billion in FY 2025 and the record-breaking number of whistleblower-filed cases. She described OIG’s February 2026 publication of the Industry Segment-Specific Compliance Program Guidance for Medicare Advantage. Finally, she indicated that OIG’s focus areas for enforcement will include risk adjustment, direct-to-consumer pharmaceutical sales, and information blocking.

CMS Deputy Administrator and Chief Operating Officer Kimberly Brandt began her presentation by joking that she had just returned from a strenuous congressional subcommittee hearing. She emphasized CMS’s goals to expand technology-driven fraud detection to identify spikes or aberrancies in claim submissions. She announced that Milliman Inc. won the agency’s “Crushing Fraud Chili Cook-Off Competition,” which was designed to identify fraud detection solutions like using artificial intelligence. Ms. Brandt anticipates that CMS will publish a white paper on Milliman’s proposal in the near future. She stressed that CMS aims to move away from the “pay and chase” model toward the “prevent and detect” model by aggressively wielding CMS’s authority to suspend billing privileges pending investigation.

Ms. Kelley for OGC, Ms. Edwards for OIG, and Ms. Brandt for CMS each ended their presentations with a note that their respective agencies are hiring and they are looking for applicants.

In a later breakout session related to hot topics in enforcement, a panel included DOJ Civil Division Assistant Director Edward Crooke, OGC Deputy Associate General Counsel for Program Integrity Brian Dupre, and OIG Assistant Inspector General for Legal Affairs Susan E. Gillin. Mr. Dupre described OGC’s approach to enforcement as “everything, everywhere, all at once,” noting a large focus on suspect DMEPOS, skin substitute, and laboratory billing.

He referred to the Fraud Defense Operations Center (FDOC), also known as the “war room,” which uses data-driven analysis to proactively detect and prevent fraud, and noted that $1.8 billion in payments were suspended in 2025. He stated that they are investigating five providers per business day.

The panel also highlighted the Wasteful and Inappropriate Services Reduction (WISeR) Model, a six-year model under the CMS Innovation Center aimed at reducing avoidable, non-evidence-based utilization in Original Medicare.

Key Takeaways

This year’s conference showcased a heavy emphasis on fraud detection and enforcement. The government’s presentations suggest that the agencies are understaffed and seeking to ramp up to enhance their enforcement efforts. Nevertheless, the government continues to roll out tech-driven tactics for aggressive fraud detection.

Stakeholders can anticipate greater governmental scrutiny deriving from any outliers in claims data, regardless of whether such outliers are problematic, and prepare for the possibility of suspended billing privileges during the pendency of governmental investigations that can drag on for extended periods of time.

Revocations, suspensions, exclusions, and decertifications can have broad impacts on providers and affiliated entities. Stakeholders participating in Medicare and Medicaid should consider additional proactive monitoring and assessments of compliance program adequacy.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.
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