The California Department of Health Care Services (DHCS) has increased monitoring of the Medi-Cal program as part of its efforts to enhance healthcare quality, access, and equity among beneficiaries. DHCS has been able to refine its Medi-Cal Managed Care Plan (MCP) contracts and sub-regulatory guidance, such as All Plan Letters (APLs) and policy manuals, to define what is expected of the program and in which situations enforcement measures, including corrective action plans and administrative or monetary penalties, can be implemented.
According to publicly available DHCS audit reports of 2024 and 2025, with these reforms, a significant portion of MCPs still have operational issues. The audits, spanning six major domains, reveal compliance gaps and underlying causes in various plans and delegated entities.
Auditors mentioned deficiencies across:
In Population Health Management and Care Coordination, DHCS found that failure to accomplish Initial Health Appointments (IHAs) within needed periods, mismanagement of continuity of care (COC) requests, persistent gaps in blood lead screenings and anticipatory guidance of young children, and nonadherence to Enhanced Care Management (ECM) requirements, such as lack of a health risk assessment and a care management plan.
The audits of the Access and Availability of Care revealed that there were cases wherein MCPs did not receive valid Physician Certification Statements for non-emergency medical transportation services.
The DHCs reported failure to resolve grievances promptly, inadequate grievance resolution letters, and a lack of timely medical director review of quality-of-care grievances under member rights.
In Quality Management, multiple plans were cited for insufficient investigation and tracking of Potential Quality Issues (PQIs).
Administrative and Organizational Capacity
Administrative and Organizational Capacity audits were characterized by delays in essential reporting of fraud, waste, and abuse (FWA).
According to DHCS, many of the deficiencies stem from gaps between written policies and day-to-day operations. Fragmented workflows, reliance on delegated vendors, limited oversight, and legacy technology systems with poor interoperability continue to hinder consistent compliance. In several cases, corrective actions implemented after prior audits were deemed insufficient, resulting in repeat findings across audit cycles.
The audit outcomes underscore the need for:
The Hawaii Department of Human Services (DHS) has released a memo with new care and billing guidelines for Integration (QI) health plans and providers working in early childhood mental health.
According to the DHS memo, the updated guidelines emphasize the use of the DC:0–5™ Diagnostic tool, integrating with existing billing codes.
DHS has made several educational resources available.
You are advised to contact Provider Services at 888-980-8728 for assistance.
The Texas Medicaid & Healthcare Partnership (TMHP) has expanded the provider types eligible for reimbursement related to revakinagene taroretcel-lwey (Encelto) under procedure code J3403. This update was last revised on January 16, 2026.
Starting February 01, 2026, TMHP will begin considering claims for Encelto (J3403) when the service is provided by approved providers working through:
This applies when services are delivered in an outpatient hospital setting.
Important note for managed care claims: Texas Medicaid managed care organizations (MCOs) are required to provide all medically necessary Medicaid-covered services for enrolled members. However, administrative requirements such as prior authorization, precertification, referrals, and claims submission procedures may vary compared to traditional fee-for-service Medicaid and may differ by MCO. The providers are advised to call the particular MCO of the member to get plan-specific requirements and instructions.
Providers may call the TMHP Contact Center at 800-925-9126 with questions or support.
UnitedHealthcare has updated its national Gold Card code list, with the changes taking effect on January 01, 2026. As part of a routine program performance review, the company identified certain codes that were not being used by contracted provider groups. Those unused codes have now been removed from the official list to keep the program aligned with current utilization trends.
Providers can view the updated code list through the designated UnitedHealthcare resource page.
The UnitedHealthcare national Gold Card program is designed to recognize contracted provider groups that consistently follow evidence-based clinical guidelines. The program is applicable in various lines of business, which are UnitedHealthcare commercial plans, UnitedHealthcare Individual Exchange plans, UnitedHealthcare Medicare Advantage plans, and UnitedHealthcare Community Plans.
To contact the support or ask further questions, UnitedHealthcare welcomes providers to contact it with 24/7 chat support in the UnitedHealthcare Provider Portal.
Over the years, physician groups have been calling on Medicare to increase the rate of reimbursement, claiming that the annual payment adjustments under the program have not kept up with the actual cost of operating a medical practice.
The American Medical Association reports that the Medicare reimbursement to physician practices has decreased by approximately 33 percent since 2001, when inflation is factored in. At the same time, practice expenses have continued to climb. The Medicare Economic Index (MEI), which tracks healthcare-related inflation, increased by 3.5% in 2025, adding more pressure to already tight margins.
A major reason this mismatch continues is that CMS is legally required to keep annual physician payment updates budget-neutral. In simple terms, Medicare cannot freely raise physician rates year after year without offsetting those increases somewhere else, which makes it difficult to keep up with inflation.
In many years, Congress ends up stepping in with temporary fixes. But doctors argue this pattern creates constant uncertainty. When payment changes require last-minute legislative action, practices find it difficult to plan, staff, and invest in personnel, technology, and long-term upgrades.
To add additional stability to the Medicare physician payment, the Medicare Payment Advisory Commission (MedPAC) suggested last year that Congress should tie annual payment increases to the MEI. MedPAC specifically suggested an updated formula of MEI minus one percentage point.
This proposal was intended as a middle ground. Physician groups generally supported the idea of modernizing Medicare’s payment structure, but many wanted a more generous increase, such as MEI plus one percentage point, rather than a reduction from the index.
Now, however, MedPAC appears to be moving away from that framework, which became a key reason two commissioners voted against the group’s draft recommendation for 2027.
Commissioner Kenny Kan, a New Jersey Blues health plan executive, said MedPAC’s earlier MEI-minus-one idea followed years of effort to balance two competing realities: physicians often lose money treating Medicare patients, while Medicare must also limit long-term spending growth. Kan warned that the newly proposed approach effectively results in a 2.2% payment cut for doctors.
The second dissenting commissioner, Brian Miller, an associate professor of medicine at Johns Hopkins University, also criticized the direction of the recommendation. He said the update is especially difficult to justify when Medicare tends to provide stronger payment protection for hospitals.
Miller emphasized that the proposed MedPAC guidance would result in a negative update for physicians overall, and he argued that the policy debate is missing the bigger picture.
MedPAC Chair Michael Chernew defended the draft recommendation, explaining that MEI minus one was never meant to be a strict rule. Instead, he said it was intended as a baseline reference point, with the final payment recommendation adjusted around that benchmark.
Chernew also noted that physician revenue could end up higher than what the base rate update suggests, largely due to increased billing intensity and coding-related factors that can influence total Medicare payments.
In his view, the final impact for doctors could still be slightly above the current law once those other factors are considered.
The American Medical Association reacted by accepting the update proposed by MedPAC, but questioned the commission abandoning its previous solution. AMA Board Chairman Dr. David Aizuss said in a statement that the organization was disappointed that MedPAC had reversed the position it had taken months before regarding the payment structure it endorsed.
Aizuss emphasized that linking physician updates to the MEI would allow medical practices to have long-term predictability and safeguard patient access, which is already a significant concern in rural and underserved communities with physician shortages.
MedPAC also recommended that hospital reimbursement not be reduced under current law in 2027, along with physician payment recommendations. Commissioners re-endorsed a proposed tool known as the Medicare Safety-Net Index that is meant to allocate more resources to hospitals that serve low-income and high-need patients.
Meanwhile, MedPAC voted to suggest other Medicare spending cuts. The commission supported a 4% cut to skilled nursing facilities and a 7% cut to home health agencies and inpatient rehabilitation facilities in 2027, compared to the current law.
The Centers for Medicare and Medicaid Services (CMS) introduced a significant new audit program on January 01, 2026, which is called the Wasteful and Inappropriate Service Reduction (WISeR) Model.
The goal of WISeR is straightforward. CMS aims to reduce wasteful and low-value care by focusing on a limited list of Medicare-covered services that have been, or are at risk of becoming, vulnerable to fraud, waste, or abuse. Instead of reviewing everything broadly, WISeR concentrates on a specific set of services and uses technology-supported workflows, including artificial intelligence (AI), to review claims before Medicare pays.
To do this, WISeR relies on two review methods:
Authorized WISeR participants handle both processes, which CMS has formally outlined. Below is a clear explanation of how the model works and what providers should expect.
Under WISeR, providers and suppliers (referred to here as Providers) located in six participating states must follow new coverage approval steps before payment is issued for selected items and services. The six states are:
Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.
Providers must use one of the following two routes to receive a coverage decision for WISeR-selected services:
CMS explains these pathways in its official WISeR infographic.
WISeR applies to services performed in four common care settings:
The services included in WISeR are generally elective or planned procedures that already have clear Medicare coverage rules available through sources such as Medicare laws, regulations, National Coverage Determinations (NCDs), and Local Coverage Determinations (LCDs).
CMS has identified multiple categories of services for review under this model. These include:
A key difference with WISeR is that technology companies, not healthcare providers, serve as the main participants in the model. These companies test advanced systems like AI and machine-learning tools to support prior authorization decisions and pre-payment review determinations.
CMS has chosen six technology firms as WISeR “model participants.” CMS describes these participants as companies with proven experience managing prior authorizations using enhanced technology for other payer systems, including Medicare Advantage.
Even though Medicare Administrative Contractors (MACs) will still operate in their usual roles, the WISeR participants will handle the actual work tied to:
These WISeR participants earn incentive payments based on a percentage of savings achieved through reduced spending under the model. CMS has stated that the payment approach is intended to encourage accurate decisions, fast turnaround times, and clearer communication rather than driving denials.
CMS also plans to actively track denial activity. If a participant shows poor performance or quality issues, CMS may lower their payments or remove them from the model entirely.
WISeR began officially on January 01, 2026. On January 05, 2026, the WISeR participants started to accept submissions of prior authorization.
These prior authorization requests apply to services performed on or after January 15, 2026. CMS also released updated FAQs that address the operational readiness of WISeR electronic portals.
The WISeR Provider and Supplier Operational Guide includes two critical appendices:
Associated codes in Appendix B do not require prior authorization if the primary service was properly submitted and approved. However, those related codes may still be denied in cases where:
CMS indicates that associated codes should only be flagged when a related primary code appears on the claim and that primary code was not affirmed.
For Providers, the practical answer is no.
CMS refers to WISeR as “voluntary,” but that label appears to apply only to the technology companies participating in the model. Providers in the impacted states are not able to opt out.
Providers must either:
CMS has also mentioned it may explore a future gold carding approach, which could exempt Providers from prior authorization if they consistently receive high affirmation rates.
Providers operating in WISeR states should prepare for increased documentation expectations and tighter controls on selected services.
UnitedHealthcare has announced significant improvements to its Provider Portal to provide healthcare practices with increased control and visibility of received payments directly from the members. The update makes the process of delivering, tracking, and reconciling virtual payments simple and does not affect the current processing timelines.
Just like in the previous case, members' virtual card payments (VCPs) must be processed by the providers within 30 days; otherwise, they are automatically refunded to the member.
The new Payment Preference Center in Profile and Settings enables practices to review how members pay them. Virtual card payment is the default payment system. It’s a secure, digital way to transmit payments.
In case practices choose not to use VCPs, and they want to bill directly, they can opt out of VCPs. Other options, like paper checks or straight-through processing (STP) VCPs as a method of member payments, are not made available until later in 2026.
The 24/7 chat service is accessible on the UnitedHealthcare Provider Portal for providers who have questions.
The ACCESS Model, also known as Advancing Chronic Care with Effective, Scalable Solutions, was published by CMS on December 01, 2025. It is a voluntary ten-year initiative, and its aim is to provide better care to the Medicare patients with chronic conditions, which would lead to more regular and quality care over the period of time.
The announcement reinforces CMS’s push toward value-based care and signals a bigger role for technology-enabled care delivery, with new upside as well as new accountability for participating organizations.
At the center of ACCESS is a new payment approach called Outcome-Aligned Payments. Instead of primarily compensating for a list of tasks that have to be checked, CMS will compensate for improvements in patient health that can be measured. The organizations enrolled will be provided with stable, planned payments to manage eligible conditions, but the full value is acquired only in case patients are able to meet specific clinical goals, including improved blood-pressure control or less pain. Care can be rendered physically, virtually, or asynchronously, whichever is most appropriate to the patient.
ACCESS is meant to supplement traditional chronic care by closing common gaps in long-term condition management using outcome-based reimbursement and technology-supported care. In practice, it encourages providers to choose the tools, workflows, and clinical methods that produce results, rather than simply proving that steps were performed.
To be eligible, a person needs to be enrolled in Medicare Part B, but CMS restricts certain types of suppliers (including DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) suppliers and lab suppliers) from joining. The interested organizations will need to complete the ACCESS Model Interest Form and begin evaluating the preparedness of the digital health adoption.
Outcome-Aligned Payments: Payments that are fixed, installment-based, and dependent on achieving particular clinical targets.
Advanced technology care: The model incorporates remote care, digital health care devices, and virtual care solutions in its design.
Condition-specific tracks: Special tracks of the model include cardiometabolic, cardio-kidney-metabolic, musculoskeletal, and behavioral health. The participants will be expected to cope with all the conditions in the chosen track and provide patient-centered care.
Joining ACCESS is not a “plug-and-play” decision. It will likely require operational changes and tighter clinical execution. Providers should start by looking at whether their current systems can support remote monitoring at scale and produce reliable reporting. The next question is workflow fit: how will new tools integrate into day-to-day care without adding friction for clinicians or patients? The financial side matters too. Because payments are tied to outcomes, performance shortfalls can translate into revenue risk, so organizations need a clear plan to consistently meet CMS benchmarks.
ACCESS represents a stronger shift toward technology-enabled, patient-centered chronic care in traditional Medicare. For early providers, it can be a chance to lead in modern chronic condition management and differentiate through measurable outcomes. But results will depend on strong data capabilities, practical patient engagement plans, and tight alignment with CMS quality expectations.
The ACCESS Model signals a major push toward faster digital health adoption within traditional Medicare, creating new pathways for technology-driven chronic care.
The U.S. Centers for Medicare and Medicaid Services has introduced a new payment-model demonstration that comprises Accountable Care Organizations (ACOs). The program is known as the Long-term Enhanced ACO Design (LEAD) and is intended to enhance work and outcomes of patients with serious or complicated conditions, particularly those who are nearing the end of life.
LEAD will come to substitute the ACO Realizing Equity, Access, and Community Health (REACH) demonstration, which will expire in 2026. It is developed to promote closer collaboration of a broader range of healthcare providers and environments.
LEAD is one of CMS’s longest payment demonstrations, with a 10-year performance window running from January 01, 2027, through December 31, 2036, on a voluntary basis.
The industry leaders in the aging services and home-based care feel that the emphasis on high-needs patients under the model, coupled with additional flexibility, can result in prompt and more frequent coordination of the care providers in the cases of complex and chronic cases. LEAD uses a capitated, population-based payment approach that is meant to drive value-based arrangements, promote proactive care delivery, and reduce fragmented transitions between settings. The structure can also support additional risk-based payment approaches among a wide variety of provider organizations.
CMS has described LEAD as an effort to improve benchmarking and attract a wider set of participants, including providers serving specialized populations and organizations that are newer to ACO participation, such as smaller, independent, or rural practices. Many of these groups have historically avoided ACO models or exited them due to financial and administrative burdens. LEAD aims to reduce those barriers through more flexible, predictable cash-flow payments and expanded supportive tools intended to boost bedside clinical capacity and meet specialized patient needs.
LEAD’s core goals include:
The model is aimed at integrated care of high-need groups, including dual-eligible Medicare-Medicaid patients and home-bound or home-limited patients.
In the initial planning phase, between March 2026 and December 2027, CMS will select two states with which it will liaise to develop an ACO-Medicaid partnership arrangements framework.
This framework is expected to outline how ACOs and Medicaid organizations could share data, coordinate care, and improve outcomes and patient engagement.
Another distinctive component is CMS support for “CMS Administered Risk Arrangements (CARA),” which helps participating LEAD ACOs design embedded risk arrangements with specialists and other provider organizations. This feature will enhance the power of preferred provider relationships and permit episode-based risk designation in the broader model.
In general, LEAD aims to enhance the complexity of high-needs patient coordination by enhancing health networks, incentive alignment, and the development of structured and patient-focused care throughout the continuum, particularly in advanced illness and end-of-life.
To meet state requirements, effective January 1, 2026, prior authorization will be required for most incontinence products when the services provided exceed the monthly monetary benefit limit for UnitedHealthcare Community Plan of Indiana members. This update applies to both Indiana PathWays for Aging and Hoosier Care Connect.
This policy impacts most incontinence items. However, certain incontinence product service codes (see Table 10) are eligible for coverage above the monthly limit.
Prior Authorization Guidelines
How to submit New or Updated Requests
Fax the completed universal provider authorization fax form along with all supporting medical-necessity documentation.
