CMS & CMMI Updates

Key Actions:

CMS took a major program-integrity action by announcing a six-month nationwide enrollment moratorium on new Medicare hospice and home health agency enrollments, framed as an “aggressive nationwide crackdown” on fraud (CMS press release). The action signals heightened scrutiny in two high-growth, high-risk post-acute sectors that are central to ACO and Medicare Advantage care-continuum strategies.

CMS also issued Transmittal R13775PI / CR 14475, effective June 15, 2026, clarifying the offering and reporting of Targeted Probe and Educate (TPE) one-on-one education under the Medicare Program Integrity Manual, Pub. 100-08 (R13775PI). This affects how Medicare Administrative Contractors document provider education during medical review.

On interoperability, CMS announced early adopters for electronic prior authorization solutions ahead of the 2027 requirements, accelerating implementation of payer-provider API workflows and automation infrastructure (CMS press release). This is directly relevant to MA plans, Medicaid managed care, CHIP, and QHP issuers preparing for federal prior authorization data-exchange requirements.

CMMI-related activity included publication of the ACO REACH Model Data Dictionary 2024–2025, updating technical documentation for model data users and participants (ACO REACH Model Data Dictionary 2024-2025). CMS/HHS also announced the first meeting of a Healthcare Advisory Committee, suggesting formalized stakeholder input under HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz (HHS and CMS announcement).

The enforcement backdrop intensified: OIG highlighted unclear Medicare requirements for inpatient rehabilitation facility documentation, coverage, and billing (OIG IRF report), while DOJ/OIG actions included a $197M Medicare fraud sentence (OIG release), a $300,000 False Claims Act settlement involving skilled nursing rehabilitation services (OIG release