Today, the Eleventh Circuit heard oral argument in United States ex rel. Zafirov v. Florida Medical Associates, LLC, a case addressing the constitutionality of qui tam relators that has drawn national attention. At stake is the future of qui tam whistleblower actions under the FCA—a statutory scheme that has, for decades, empowered private individuals to bring fraud claims on behalf of the federal government.Continue Reading Eleventh Circuit Hears Oral Arguments in High-Profile Challenge to Constitutionality of The False Claim Act’s Qui Tam Provision

The Centers for Medicare & Medicaid Services (“CMS”) final rule for Medicare payment for services provided in hospital outpatient departments (paid under the Outpatient Prospective Payment System or “OPPS”) and ambulatory surgery centers (“ASCs”) during calendar year (“CY”) 2026 (the “Final Rule”) largely adopts CMS’ proposed changes to advance President Trump’s policy directives to:Continue Reading CMS Finalizes Medicare Payment Policies for Hospital Outpatient and Ambulatory Surgery Center Services

The Centers for Medicare and Medicaid Services (“CMS”) recently announced the first six participating states in the Wasteful and Inappropriate Service Reduction (“WISeR”) Model that will begin on January 1, 2026: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.[1] As its hallmark objective, the Model aims to refine prior authorization processes for traditional fee-for-service Medicare through the use of enhanced technologies, such as artificial intelligence (“AI”), to reduce the performance of, and payment for, services that are deemed to be “low value.” Model participants will receive a percentage of the savings associated with avoided “wasteful, inappropriate care” as a result of their reviews.Continue Reading New WISeR Model Aims to Leverage AI Technology to Reduce Costs and Inefficiencies

The California Department of Health Care Services (“DHCS”) announced via a Policy Letter that the state has paused the application process for Program of All-Inclusive Care for the Elderly (“PACE”) organizations for a minimum of two years.[1] Beginning November 20, DHCS will not accept applications to establish new PACE organizations or accept service-area expansion requests from existing programs. The letter makes clear that the pause is tied to DHCS’s oversight responsibilities under the Welfare & Institutions Code and reflects the agency’s need to manage growth and maintain the integrity of the program.[2]Continue Reading California Issues Two-Year Freeze on PACE Applications: What Providers Need to Know

On November 25, 2025, CMS released the Contract Year (“CY”) 2027 Medicare Advantage (“MA”) and Part D proposed rule (the “Proposed Rule”). The Proposed Rule would make significant changes to the MA and Part D programs, including revising measures under the Star Ratings program, creating a new special enrollment period for enrollees impacted by a provider termination, expanding access to risk adjustment data, relaxing requirements for marketing and communications materials, shortening certain record retention requirements, and easing certain requirements for offering dual eligible special needs plans (“D-SNPs”). In addition, as previewed in the CY2026 final rule and CMS memoranda to plans, the Proposed Rule would rescind several regulatory requirements promulgated under the prior administration. The Proposed Rule also codifies existing CMS guidance in several areas including Part D Redesign. Finally, the Proposed Rule includes several requests for information that are focused on “approaches and opportunities to streamline regulations and reduce administrative burdens on providers, suppliers, beneficiaries, and other interested parties participating in the Medicare program.”Continue Reading Happy Holidays? CMS Contract Year 2027 Medicare Advantage and Part D Proposed Rule Has Winners and Losers

In early August, Illinois enacted the Wellness and Oversight for Psychological Resources Act (HB 1806, or the “Act”), making it the first state to pass a law regulating the use of AI[1] in the delivery of therapy and psychotherapy services. The Act, which took immediate effect, imposes guardrails on the use of AI to provide decision-making therapeutic support services, but permits the use of AI for administrative and supplementary tasks, subject to certain consent requirements. This blog post summarizes the Act and addresses its potential implications for the use of agentic AI by Illinois therapy providers.Continue Reading Illinois Becomes the First State to Regulate the Use of AI Mental Health Therapy Services

The Centers for Medicare & Medicaid Services (“CMS”) recently finalized a rule establishing the new Ambulatory Specialty Model (“ASM”)— a mandatory value-based payment model that could apply to nearly one-quarter of all physicians in select specialties starting January 1, 2027. The ASM applies to physicians providing services to address two high-expenditure chronic conditions among Medicare patients: heart failure (cardiology) and low-back pain (pain management, interventional pain, neurosurgery, orthopedic surgery, and physical medicine and rehabilitation). Participation will be mandatory for eligible clinicians practicing in geographic areas selected by CMS that will likely encompass approximately one-quarter of U.S. Core-Based Statistical Areas (“CBSAs”) or metropolitan divisions nationwide. Published in connection with the Calendar Year (“CY”) 2026 Medicare Physician Fee Schedule (“PFS”), this alternative payment model represents a significant step in CMS’s transition toward specialty-specific accountability for cost, quality, and care coordination in ambulatory care. The model has significant implications for specialty practices, particularly those participating in or aspiring to join Accountable Care Organizations (“ACOs”). Additionally, the ASM will leverage components of the existing Merit-based Incentive Payment System (“MIPS”)/Medicare Value Pathways (“MVPs”) frameworks. For clinicians subject to MIPS/MVP, this model introduces a revised approach to performance scoring under a familiar framework.Continue Reading CMS Finalizes Mandatory Ambulatory Specialty Model for Cardiology and Low-Back Pain

Persistent workforce shortages continue to define the post-pandemic healthcare landscape. Hospitals, health systems, and long-term care providers report enduring deficits in nursing, primary care, and behavioral health staffing, with projections indicating that these shortfalls are likely to persist through the next decade.[1]Continue Reading Navigating Healthcare Workforce Shortages: Evolving Scope-of-Practice and Staffing Regulations

California continues to lead the nation in artificial intelligence (“AI”) regulation with the recent enactment of Senate Bill (“SB”) 53—the Transparency in Frontier Artificial Intelligence Act (“TFAIA” or the “Act”)[1]. Signed by Governor Gavin Newsom earlier this fall, the TFAIA takes effect January 1, 2026, and establishes significant oversight, accountability, and reporting requirements for advanced developers at the cutting edge of artificial intelligence. This law sets a framework for transparency and public safety, and is expected to set a nationwide precedent for future AI legislation to come.Continue Reading California Enacts SB 53: A Defining Step in Responsible AI Governance for Frontier AI Developers

For years, the conversation around health insurer consolidation and vertical integration has simmered through antitrust inquiries, oversight hearings, and policy papers. The Patients Over Profit Act (the “POP Act”)[i], introduced in both chambers of Congress this fall, marks a decisive shift. Rather than regulating insurer-provider integration, the POP Act proposes to ban it outright.Continue Reading Patients Over Profit Act: A Federal Inflection Point on Insurer-Provider Integration and What Comes Next