The current ABN form, Form CMS-R-131, expired on January 31, 2026, as a recent update posted by Noridian Healthcare Solutions, the Durable Medical Equipment Medicare Administrator Contractor (DME MAC) of Jurisdiction D.
The Centers for Medicare and Medicaid Services (CMS) is currently developing a revised version of the Advance Beneficiary Notice of Noncoverage (ABN) form. The official announcement and implementation guidance will be issued when the revised ABN is completed. These will be updated on the CMS as well as the Noridian websites.
DME suppliers and other Medicare providers are advised to use the existing ABN format until further notice. Noridian recommends that the providers visit the following websites closely to get updates about the revised ABN form and implementation timelines:
An Advance Beneficiary Notice refers to a written notice provided to the Medicare beneficiaries by their providers before providing an item or service. ABNs must be issued in case healthcare providers (such as DME providers, physicians, practitioners, and independent laboratories) anticipate rejection based on statutory exclusions by Medicare for any item or service.
The Centers for Medicare & Medicaid Services (CMS) finalized the “Preserving Medicaid Funding for Vulnerable Populations, Closing a Health Care-Related Tax Loophole Final Rule,” strengthening federal oversight of Medicaid provider taxes. This is a vital financing tool adopted by the state Medicaid agencies to finance their portion of Medicaid spending.
The policies align with several provisions of the One Big Beautiful Bill Act (OBBBA), the Medicaid Fiscal Accountability Rule of 2019, and the framework outlined in the proposed rule on which industry stakeholders, including AHCA/NCAL, previously submitted comments. According to CMS, the rule is aimed at sealing loopholes, promoting fiscal responsibility, and ensuring that Medicaid funding mechanisms do not unreasonably target providers of high Medicaid beneficiaries.
To determine the operational effect on states, CMS has provided a tier transition period whereby the state Medicaid agencies are given time to align existing, noncompliant provider taxes to the new federal regulations under Section 71117 of the OBBBA. These standards restrict the use of waivers from long-standing requirements that provider taxes be uniform, broad-based, and generally redistributive, and prohibit differential tax rates based on Medicaid volume.
CMS has provided the following three-track compliance schedule:
AHCA/NCAL reaffirmed its support for statutory compliance and Medicaid fiscal integrity while cautioning against unintended consequences that could affect access to long-term services and supports.
Hospice providers in Georgia and Ohio are being encouraged to get ready to face increased federal scrutiny due to new enforcement measures announced by the Centers for Medicare and Medicaid Services (CMS).
In December 2025, both states were included in the Provisional Period of Enhanced Oversight (PPEO) and Expanded Prepayment Review (EPR) programs, which subject claims to medical review before payment. The action will expand the control on hospice providers in Arizona, California, Nevada, and Texas.
According to CMS data released in June 2025, 668 hospice providers nationwide were subject to PPEO, and 122 had their Medicare enrollment revoked as a result of oversight findings.
PPEO and EPR are administrative measures that aim at paying close attention to hospice providers deemed to pose a high level of compliance or fraud risk. Medicare Administrative Contractors (MACs) under such programs can hold claims for medical review before payment. This implies that further documentation must be provided before claims can be approved for reimbursement.
Where providers have shown high rates of error relating to clinical eligibility, CMS can take corrective measures, revoke billing rights, or suspend Medicare enrollment.
PPEO or EPR is implemented by CMS and its MACs on the basis of certain risk indicators, as stated in the table. The scope and duration of oversight vary by MAC and CMS directive.
| Trigger | What Happens |
| New Enrollment | Hospices initially enrolling in Medicare in the targeted states are typically placed into PPEO. Early claims are subject to prepayment medical review before routine payment resumes. |
| Change of Ownership | Ownership changes that meet the criteria under 42 C.F.R. § 489.18 or certain 100% ownership changes outside that regulation can result in the hospice being treated as “newly enrolled” for oversight purposes and placed into PPEO. |
| Material Enrollment Changes | Significant enrollment events (e.g., reactivation after deactivation) may prompt MAC risk-based scrutiny. Depending on risk, a hospice could be placed into PPEO or selected for EPR. |
Check out the CMS guidance document on enhanced oversight for hospices.
Under prepayment review, selected claims are suspended while MACs issue Additional Documentation Requests (ADRs) to verify medical necessity and billing accuracy.
Providers should expect:
The period of oversight can be from 30 days to one year, and the medical review authority of CMS can be extended even when a PPEO formally ends. Although the providers have the right to appeal, the appeal process can greatly delay payment schedules.
According to industry experts, hospice providers in Georgia and Ohio need to take the initiative to minimize compliance risk. Some of the preparatory measures are:
The Texas Health and Human Services Commission (HHSC) has made its Electronic Visit Verification (EVV) Survey available and is encouraging users of the EVV system to give feedback.
The survey will be used to gather expectations for the EVV program, help improve current procedures, and prioritize new updates, such as policy or system updates.
The survey should be completed by:
The EVV Survey is available through Feb. 28.
If you have questions, you can email HHSC EVV Operations
The Centers for Medicare and Medicaid Services (CMS) has really stepped up enforcement and monitoring activities to safeguard consumers against unauthorized enrollments in health plans and further enhance the integrity of the Affordable Care Act (ACA) Exchanges. These measures, as reported in a new CMS fact sheet, have already led to almost $10 billion of annualized savings and a significant reduction of fraudulent and improper enrollment activity on the Federally-facilitated Exchange (FFE) platform.
During the last year, CMS used all its statutory and regulatory authority to deal with unauthorized enrollments, inappropriate switching of plans, and ineligible receipt of advance premium tax credit (APTC). As part of these, CMS terminated premium subsidies for almost 1.5 million individuals who were discovered to be ineligible to receive financial assistance or signed up without their approval.
Over one million of them were both enrolled in Medicaid or the Children's Health Insurance Program (CHIP) and receiving Exchange subsidies, or did not file and reconcile previously-received tax credits.
Moreover, CMS suspended the coverage of about 250,000 consumers who enrolled in Exchange plans without permission, enabling the agency to reclaim unnecessary federal subsidies. According to CMS, all these actions produced nearly 10 billion dollars in savings on an annualized basis.
Program Integrity Processes |
Approximate Number of Enrollees |
| May 2025 Medicaid/CHIP Periodic Data Matching |
435,000 |
| August 2025 Medicaid/CHIP Periodic Data Matching |
115,000 |
| Unauthorized Enrollment Cancellations Performed in 2025 | 250,000 |
| Failure to File and Reconcile for Plan Year 2025 | 235,000 |
| Failure to File and Reconcile for Plan Year 2026 (In Progress) | 430,000 |
CMS provided several initiatives that would protect consumers and taxpayer funds:
CMS finalized regulations to reduce incentives for improper enrollments and strengthen eligibility verification. Key provisions include:
CMS has enhanced its response to consumer complaints of unauthorized enrollments and plan switches. CMS also reduced the period of time it took to cancel policies that were associated with confirmed complaints.
CMS also restored bi-annual Medicaid and CHIP Periodic Data Matching (PDM) tests that had been suspended in the COVID-19 public health crisis. These screenings found and rectified cross-enrollments in Medicaid, CHIP, and Exchange coverage with APTC.
The CMS also collaborated with 20 state-based Exchanges (SBEs) to determine their progress in preventing concurrent enrollments. The states that had integrated Medicaid systems resolved at least 98 percent of the identified cases, whereas the rest were instructed to adopt corrective action plans.
CMS reinstated the removal of APTC in 2025 for consumers who did not submit tax returns and reconcile subsidies for two consecutive years. This measure eliminated subsidies for almost 200,000 households within the states of the HealthCare.gov. CMS has already eliminated APTC on about 366,000 households through the 2026 auto-reenrollment process and is continuing.
CMS continues to monitor agent, broker, and enhanced direct enrollment entity performance and has taken enforcement action where necessary. In December, CMS ended an 18-month investigation of subsidiaries of Speridian Technologies, including Benefitalign and TrueCoverage.
CMS continues to educate consumers on avoiding fraudulent enrollment practices and encourages individuals who believe they were enrolled or switched without consent to contact the Marketplace Call Center at 1-800-318-2596. Suspected fraud can also be reported to the HHS Office of Inspector General Hotline.
The Centers for Medicare & Medicaid Services (CMS) has directed the State of Minnesota to temporarily limit Medicaid provider enrollment across multiple service categories, citing concerns over potential fraud and unusually rapid growth in provider participation and payments. The order is accompanied by a larger conflict between Minnesota and the United States Department of Health and Human Services (HHS) that has taken action to withhold over 2 billion dollars of federal Medicaid funds to the state.
The Minnesota Department of Human Services is currently challenging the decision of HHS to withhold federal Medicaid funds. CMS stated, “CMS analysis of Minnesota Medicaid data shows extraordinary growth in provider enrollment and payments for several of these services that is inconsistent with beneficiary growth and service utilization trends.” The federal officials made a conclusion that Minnesota had not done enough to curb the risk of fraud in its Medicaid program.
CMS has responded by asking Minnesota to temporarily limit new Medicaid enrollments in 13 categories of providers that CMS considers to be high-risk. These include:
The state had already declared a freeze of two years on the licensing of some of the home- and community-based services and adult day programs.
The Medicaid provider enrollment moratoria authority was introduced as a program integrity addition in 2010 through the Affordable Care Act. It is based on these provisions, defined in the Social Security Act, Section 1902(kk)(4)(B), and the Code of Federal Rules, Part 455, that CMS can direct states to place temporary enrollment limits whereby some types of providers are found to be high-risk providers of fraud.
Under federal regulations, CMS must consult with the State Medicaid Agency before a moratorium is imposed. Although SMA might choose not to take action on a moratorium on the grounds that this would greatly impact beneficiary access. The initial term of a moratorium is six months and may be extended thereafter by the SMA in six-month increments.
There should be higher compliance and administrative demands on the providers working within the affected categories. Recertification of current enrollments will likely increase, and it may cause delays and increased paperwork. Also, organizations might struggle to recruit new professionals if the enrollment requirements reduce the number of Medicaid provider-approved professionals.
The Centers for Medicare and Medicaid Services (CMS) has renewed its directive to all Special Needs Plans (SNPs) that all eligible healthcare providers must complete initial and annual Model of Care (MOC) training. This is a requirement for both in-network providers who have been contracted to treat SNP members and out-of-network providers who have regular patients with SNP.
To facilitate compliance, UnitedHealthcare has offered a self-paced SNP MOC training program that can be done in about 10 minutes. CMS obligates the providers to complete training on or before December 31, 2026.
Important Details
Further guidance and reference materials can be found here:
Any questions about the training or compliance requirements can be made to the UnitedHealthcare SNP MOC training team at snp_moc_providertraining@uhc.com.
The Centers of Medicare and Medicaid Services (CMS) has created an online complaint form where healthcare providers can post complaints on the basis of Medicare Advantage (MA) plans. The program will enhance accountability of the MA plan performance and, at the same time, make sure that the issues of beneficiary access and care are effectively tackled.
CMS has explained that anything to be reviewed must be beneficiary-oriented. The form must also include detailed information when it is filled in by the provider. Some of the information that is supposed to be provided includes the details of the complainant, beneficiary, provider, MA plan, a complaint summary, date(s) of service, and claim number.
Complaints that are sent are automatically directed to the Health Plan Management System (HPMS) Complaints Tracking Module (CTM). CMS will consequently examine and screen every complaint and allocate a contract number. It is important to note that since the entire process is online, the MA plans will never get a copy of the original provider complaint form.
The American Health Care Association (AHCA) was pleased by the development, and it highlighted that it has long been promoting a provider-based complaint mechanism. AHCA says that the new process will aid in identifying barriers to beneficiary access in a timely manner, and data provided by the CMS can be acted upon to identify patterns and track compliance among MA plans. AHCA is urging providers, especially skilled nursing and post-acute care environments, to utilize the form to provide details on ongoing access and care-delivery issues.
The questions that the providers may have on the new complaint process will refer to the AHCA Population Health Policy Analyst, Rohini Achal, or Nisha Hammel, Vice President of Reimbursement Policy and Population Health.
Thompson Coburn partner Milada Goturi was a co-presenter at a program hosted by the American Health Law Association, which was titled “Navigating Billing and Compliance Issues for Advance Practice Professionals.” The program addressed the important regulatory aspects since healthcare organizations are becoming more dependent on nurse practitioners and physician assistants, also referred to as Advanced Practice Professionals (APPs).
The increasing volumes of patients, ongoing shortages of physicians, the increasing cost of operations, and the narrowing reimbursement are the factors that are stimulating the increased use of APPs. Although APPs are generally known to positively impact access to care, patient and provider satisfaction, enhancing efficiency, and cost savings. But the broadening of their responsibilities has also escalated the risks of billing and compliance in healthcare providers. These are:
One of the main aspects of the discussion was meeting Medicare billing requirements. Medicare allows a number of billing methodologies of APP services, such as direct billing, incident-to billing, and split (or shared) billing. Every approach has its own rules and restrictions. For example, the incident-to billing should never be applicable in a hospital setting, and split/shared billing cannot be applied in a physician's office setting. Providers are vulnerable to audits and enforcement of these billing models due to their misuse. Private payors may or may not follow Medicare billing requirements.
Another significant compliance area was pointed out to be state professional licensure laws. The jurisdiction requirements are very different, as some states permit APPs to practice fully and others require a certain number of physicians to oversee them. The practices should comply with state-specific regulations, such as limits on the ratio between physicians and APPs, the documentation of the necessary chart or medication review, and the need to have on-site physicians.
Lastly, the program also placed much importance on aligning the use of APP with the hospital licensing regulations, Medicare Conditions of Participation, and accreditation requirements. All the frameworks can have extra requirements that influence the form of the APP services structure and implementation.
The Centers for Medicare & Medicaid Services (CMS) has finalized a significant and long-anticipated update to Medicare physician supervision requirements as part of the Calendar Year (CY) 2026 Medicare Physician Fee Schedule. Effective January 1, 2026, CMS will permanently allow physicians “direct supervision” through real-time, two-way audio and visual telecommunications, eliminating the long-standing requirement for a physician’s physical, on-site presence in many care settings.
Under the new rule, the presence of a supervising physician or other qualified practitioner is necessary during the entire performance of a service that must be directly supervised. However, they may do so remotely through interactive audio-video technology. Audio communication only is not up to standard. This policy marks a shift from historical Medicare regulations, where the overseeing practitioner has to be physically present in the office suite but not always in the same room as the patient.
Virtual direct supervision was first introduced by CMS in the COVID-19 public health emergency and then extended to December 31, 2025. In the eventual change, CMS mentioned better access to care among the patients, flexibility of schedules, and modernization of the care as the main reasons why the policy should become permanent.
The updated definition of direct supervision applies to many incident-to services under 42 CFR § 410.26, diagnostic tests under 42 CFR § 410.32, pulmonary rehabilitation services under 42 CFR § 410.47, and cardiac rehabilitation and intensive cardiac rehabilitation services under 42 CFR § 410.49. This flexibility has also been granted by CMS to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
Nevertheless, CMS retained more excessive demands on surgical operations of a higher risk. The services with the global surgery indicators 010 (minor, 10-day global) and 090 (major, 90-day global) will still presuppose the physical, on-site presence of the physician so that patient safety can be ensured and prompt intervention can be provided.
The policy alteration will possess extensive operational and financial consequences. In the case of incident-to-services, physicians can now oversee the activities of the auxiliary personnel, like nurses or technicians, remotely but still charge using their own Medicare account number. This will enable the off-site ordering physicians to oversee and charge incident-to services, as long as they can access them through real-time audio-video communications, which could enhance the clinical supervision and the reimbursement process.
There is also an expectation of significant gains for Independent Diagnostic Testing Facilities (IDTFs). Several diagnostic imaging services, especially those that relate to contrast, would need direct physician supervision. Virtual capabilities to achieve this need could facilitate the staffing issue, better access to imaging services, and minimize operational inconveniences due to the limitation of the availability of physicians.
CMS stressed that the providers should go out of their way to ensure that they comply with the new rules. It is also recommended that healthcare organizations should revise the supervision protocols, provide adequate telecommunication platforms capable of facilitating real-time audio-visual interaction that is secure, and articulate the supervision arrangements to withstand any kind of audit. Also emphasized in CMS was the HIPAA compliance, as there is the exchange of protected health information on the virtual supervision.
Besides this, the providers are advised to seek the advice of the relevant accreditation agencies, such as the American College of Radiology and the American Society of Radiologic Technologists, to ensure that they are following the professional standards.
The move by CMS to permanently update direct supervision conditions is a significant change in Medicare policy, which marks a further transition to technology-based care delivery against the background of access, efficiency, and patient safety.
