Author: WadeEmmert

Artificial Intelligence

• Houston Methodist is teaming up with Ambience Healthcare to integrate AI into emergency departments and inpatient care settings to address documentation and workflow challenges. The technology will capture provider-patient conversations, gather details for admissions and documentation, extract information from charts, and understand specific coding needs of each care setting. Emergency department clinicians report high burnout levels and complete approximately 4,000 mouse clicks during busy shifts, while the new AI aims to reduce this “click mileage” by eliminating copy-pasting documentation. Dr. Jordan Dale, chief medical information officer at Houston Methodist, stated they are committed to finding new ways to relieve clinicians with AI technology that enhances the patient-provider experience.
• The University of Texas Medical Branch (UTMB) uses AI to automatically analyze all CT scans for cardiac risk, identifying patients with coronary artery calcification who might otherwise go undetected. The system calculates an Agatston score through convolutional neural networks, categorizes patients into risk tiers, and sends automated notifications to high-risk patients and their physicians, evaluating approximately 450 scans monthly with 5-10 high-risk cases identified. UTMB also employs AI for rapid stroke and pulmonary embolism detection, with algorithms that notify care teams within seconds of imaging, and uses AI to assist with inpatient admission decisions by analyzing electronic health records.

Data Breach

• Ascension Health has announced having some of its patients’ data potentially exfiltrated following a December attack that compromised a former business partner’s third-party software. Patient information from care sites in Alabama, Indiana, Michigan, Tennessee, and Texas was inadvertently shared with the breached business partner, including names, birthdates, addresses, phone numbers, email addresses, Social Security numbers, race, gender, and clinical details. Ascension says their own systems, networks, and electronic health records were not involved in this incident. This disclosure follows a previous Black Basta ransomware attack reported months ago that affected 5.6 million individuals and disrupted Ascension’s electronic health records system and some hospital emergency care operations.

Food as Medicine

• Food as medicine encompasses nutritional interventions to prevent or treat disease through programs like medically tailored meals and produce prescriptions. Medicare Advantage offers food as medicine through supplemental benefits, special benefits for chronically ill enrollees, and the Value-Based Insurance Design Model, while Medicaid provides coverage through Section 1115 waivers and other authorities. There is uncertainty about future federal funding for food as medicine initiatives. Private funding faces challenges as employer health plans must classify food interventions as qualified medical expenses, requiring physician documentation and third-party verification.

Fraud & Abuse

• A Harlingen couple has pleaded guilty to defrauding Medicare through their business, Southwest Medical Home, which claimed to provide parts and repairs for power wheelchairs . The couple admitted to billing Medicare approximately $14 million between 2019 and 2023 for services never performed, including $736,072 for one specific beneficiary. They used the fraudulent proceeds to purchase cryptocurrency, a vehicle, electronics, collectibles, and purses. They face up to 10 years in federal prison and a possible $250,000 maximum fine.
• The Second Circuit ruled that an online healthcare appointment platform did not violate the Anti-Kickback Statute or False Claims Act when it relied on favorable OIG advisory opinions . The platform charges providers annual listing fees and additional fees for new patient bookings, with altered search rankings for those who don’t pay certain fees. A New York doctor filed a qui tam complaint alleging these fees constituted improper “success fees” that steered patients to providers willing to pay, but the court dismissed the case. The Second Circuit upheld this dismissal, finding the relator failed to establish fraudulent intent since the defendant had implemented its fee structure in accordance with OIG guidance.
• The Department of Justice has filed a lawsuit against CVS Health, Elevance Health, and Humana for allegedly paying hundreds of millions in kickbacks to brokerage platforms eHealth, GoHealth, and SelectQuote between 2016 and 2021. The complaint claims these insurers disguised illegal commissions as marketing payments to steer patients toward their Medicare Advantage plans while discouraging enrollment of people with disabilities. The case originated from a whistleblower report in 2021, with the DOJ seeking damages under the False Claims Act, while all accused companies deny the allegations and promise to defend themselves.
• The Eleventh Circuit issued a decision that requires False Claims Act plaintiffs to detail how alleged schemes caused submission of false claims to the government, not merely allege general fraudulent conduct. The court in Vargas ex rel. Alvarez v. Lincare, Inc. reversed dismissal only for the “upcoding” theory where relators provided specific patients, claim numbers, and reimbursement amounts, while affirming dismissal of co-payment waiver, automatic shipping, and kickback allegations that lacked these specifics. For the Anti-Kickback Statute claim, the court ruled that paying Contract Field Technicians for legitimate CPAP setup work does not violate the law without evidence connecting payments to referrals. The ruling emphasizes that FCA complaints must establish direct links between alleged misconduct and specific false claims rather than making “inferential leaps” or relying on conclusory statements. The Eleventh Circuit’s standard requires plaintiffs to demonstrate causation with particularity under Federal Rule of Civil Procedure 9(b), rejecting claims based on speculation or unsupported allegations.

Geriatrics

• Geriatric care managers (GCMs) from backgrounds in social work, nursing, and gerontology, partner with elder law attorneys to provide comprehensive support for aging individuals. GCMs offer services including needs assessment, care planning, crisis intervention, advocacy, guardianship evaluations, family mediation, and resource connection. This collaboration creates a holistic approach to aging-related legal and healthcare matters, ensuring seniors receive both legal counsel and practical support. For families navigating elder care complexities, the partnership between GCMs and elder law attorneys helps achieve optimal outcomes for seniors.

Medicare Beneficiaries

• Medicare requirements follow patients regardless of a provider’s cash-based practice model, with three provider categories determining Medicare billing obligations. Participating providers enroll in Medicare and accept assignment on all claims, billing Medicare directly for covered services. Non-participating providers enroll in Medicare but choose which claims to accept assignment on, must submit all claims to Medicare, and face limitations on what they can charge beneficiaries. Opt-out providers must file an affidavit valid for two years, enter specific contracts with Medicare beneficiaries, and can charge patients without Medicare limitations, though certain provider types cannot opt out of Medicare.

Provider Networks

• Network rental agreements in healthcare allow payers to access each other’s provider networks and fee schedules, which can circumvent negotiated contracts and subject providers to unfavorable rates. These arrangements may violate antitrust laws as horizontal price-fixing schemes under Section 1 of the Sherman Act, with courts applying the per se rule to find them unreasonably restrictive of trade. In January 2025, AIDS Health Foundation won over $10 million in damages after an arbitrator ruled that a network rental agreement between Prime Therapeutics and Express Scripts constituted illegal price-fixing, while a similar class action by Osterhaus Pharmacy against Express Scripts is proceeding after surviving a motion to dismiss in February 2025. Oklahoma has proposed legislation (SB789) to prohibit pharmacy benefit managers from making their provider networks available to other PBMs, potentially effective November 2025.

Staffing

• The United States District Court for the Northern District of Texas has invalidated the Nursing Home Minimum Staffing Rule that established staffing requirements for federally funded long-term care facilities. The Rule, which went into effect in June 2024, was challenged by the American Health Care Association and the Texas Attorney General who secured a nationwide injunction. The court vacated the 24/7 staffing requirement and other minimum standards, ruling that they violated the Administrative Procedure Act. In its decision, the court cited the Supreme Court’s Loper Bright ruling that eliminated Chevron Deference, determining that CMS lacked authority to impose stricter standards than the 8-hour nursing presence already specified by Congress.

Texas Medicaid

• The Texas Health and Human Services Commission denied Cook Children’s Health Plan a renewed Medicaid contract in March 2024, putting healthcare for 125,000 members at risk starting September, including 10,000 children with complex medical needs. The decision could force families to switch to one of four national for-profit plans, potentially disrupting established care relationships and eliminating local community-based coordination that has served Fort Worth families for 25 years. Cook Children’s has filed legal action against the commission after their protest was denied, while state lawmakers have introduced bills to change how Medicaid contracts are awarded to protect local healthcare management. The contract termination could impact 400 Fort Worth employees, 1,455 primary care providers, and 2,550 specialists, causing 75.6% insurance plan turnover in Tarrant County.

Affordable Care Act

• The U.S. Supreme Court heard arguments on April 21 regarding the constitutionality of the U.S. Preventive Services Task Force, which determines what preventive care health insurers must cover at no cost under the Affordable Care Act. The case centers on whether the task force’s 16 members, appointed by the HHS Secretary without Senate confirmation, are “principal officers” who require presidential appointment and Senate confirmation or “inferior officers” exempt from these requirements. Justices questioned both sides about the extent of the HHS Secretary’s supervision over the task force, with the government arguing the Secretary has sufficient oversight while plaintiffs contend the task force operates too independently. If the Court upholds the lower court ruling that found the task force’s structure unconstitutional, previously free preventive services could become subject to co-pays and deductibles.

Artificial Intelligence

• Texas Children’s Hospital has developed an AI model to assess bone age in pediatric patients, reducing radiologist image reading time by 30-50% since its November launch. The AI interprets X-rays to estimate bone age, which radiologists then verify, allowing them to focus on more complex procedures like interventional radiology. This bone age tool is part of Texas Children’s broader initiative that has produced twelve in-house AI solutions, including models for employee recognition, patient no-shows, and readmissions. The hospital maintains a comprehensive AI governance framework with representatives from clinical, operational, information security, and legal departments to ensure ethical use, prevent bias, and protect data privacy.
• The Trump Administration released two revised policies on April 3, 2025, replacing previous AI guidelines with new frameworks for federal agencies. OMB Memorandum M-25-21 encourages agencies to implement AI solutions that maximize taxpayer value while identifying healthcare applications as “high-impact AI” due to their role in medical devices, patient diagnosis, and insurance decisions. The second policy, OMB Memorandum M-25-22, requires agencies including HHS to update acquisition procedures for AI systems, establish cross-functional teams for decision-making, and ensure appropriate intellectual property terms in contracts. These updates must be completed by December 29, 2025, replacing policies from the previous administration that were rescinded through Executive Order 14179 in January 2025.

Business Associates

• Molecular Testing Labs (MTL) is suing its business associate Ntirety over alleged failures to comply with HIPAA Security Rule requirements following a March 12, 2025 ransomware attack. MTL claims Ntirety failed to implement appropriate safeguards required by their 2018 business associate agreement, which led to a breach of patient data by a suspected Russian cybercriminal group. Following the attack, Ntirety reportedly provided inadequate support and demanded payment for breach response assistance despite contractual obligations to provide such services. MTL is seeking indemnification for expenses related to the forensic investigation, breach notifications, credit monitoring, and potential regulatory actions after Ntirety failed to respond to formal demands.

Data Access and Breach

• Data silos in healthcare create fragmented information landscapes that hinder patient care, delay diagnosis, and force clinical staff to perform time-consuming clerical tasks. The Trusted Exchange Framework and Common Agreement (TEFCA) aims to break down these silos by connecting health information networks and imposing financial penalties for information blocking. Healthcare organizations can improve data integration by creating stakeholder incentives, implementing strong governance frameworks, empowering patients to control their data, and adopting cloud-native management technologies. Eliminating data silos optimizes clinical workflows, reduces errors, enables specialist collaboration, and creates a foundation for AI applications that can identify patients at risk for adverse outcomes.
• Blue Shield of California confirmed on April 9 that a misconfigured Google Analytics implementation exposed protected health information of 4.7 million patients between April 2021 and January 2024. The breach, identified as the largest healthcare data breach of 2025, potentially shared patient names, locations, gender, family size, medical services information, and search criteria with Google Ads for targeted advertising. Blue Shield stated no malicious actors were involved and the exposed data did not include Social Security numbers, driver’s licenses, or financial information. The company has advised affected members to monitor their accounts and credit reports for suspicious activity.
• The U.S. Department of Health and Human Services Office for Civil Rights has reached a $600,000 settlement with PIH Health, Inc. over HIPAA violations. The California health care network reported a June 2019 phishing attack that compromised 45 employee email accounts and exposed the protected health information of 189,763 individuals. OCR’s investigation found PIH failed to properly protect health information, conduct thorough risk analysis, and notify affected parties within the required timeframe. As part of the settlement, PIH must implement a corrective action plan including risk analysis, management planning, policy development, and staff training, which will be monitored by OCR for two years.

Fraud & Abuse

• The U.S. District Court for the Northern District of Texas reduced a $448 million False Claims Act penalty against Healthcare Associates of Texas to $16.5 million. The court ruled on February 26, 2025, that the original penalty violated the Eighth Amendment’s Excessive Fines Clause as it was over 100 times the $2.75 million in actual damages from Medicare billing violations. The jury had found HCAT submitted 21,844 false claims, but the court determined that per-claim penalties resulted in disproportionate liability compared to the rules violations at issue. The court instead applied treble damages, setting a precedent for healthcare providers to raise constitutional challenges to excessive FCA penalties.
• The Eleventh Circuit ruled that merely alleging a scheme to submit false claims does not satisfy the “reliable indicia” standard under the False Claims Act and Rule 9(b). In United States ex rel. Vargas v. Lincare, Inc., the court partially reversed a dismissal, allowing claims about battery upcoding to proceed because relators provided specific claim details, but affirmed dismissal of co-pay waiver allegations where no specific claims were identified. The ruling clarifies that relators must either allege details of specific false claims or demonstrate direct personal knowledge of claim submissions. This decision reinforces the strict pleading requirements in FCA cases within the Eleventh Circuit, rejecting the notion that describing a fraudulent scheme alone is sufficient.
• Two former laboratory sales executives were sentenced to federal prison for violating the Anti-Kickback Statute. The scheme involved two rural Texas hospitals partnering with True Health Diagnostics laboratory, where hospitals billed insurers at higher rates for blood tests and shared revenues with marketers who paid physicians for referrals through fake investment opportunities. Eight individuals were indicted in 2022 for disguising kickbacks as investment returns to physicians who ordered tests from the affiliated laboratory.

Hospitals

• Preliminary data shows that “tens of thousands” of patients who were not “lawfully” in the United States were treated by Texas hospitals in recent months and the cost for their care is in the millions of dollars. Governor Greg Abbott ordered Texas hospitals last summer to collect citizenship status information from patients, with data from 558 hospitals expected to be finalized this week. Representative Mike Olcott has proposed a bill to formalize Abbott’s order into an annual report, citing concerns about rural hospital closures due to uncompensated care. Texas hospitals spend $3.1 billion annually on uninsured care, though advocates note much of this cost comes from the 4 million uninsured Texas citizens rather than non-citizens. The data collection began in November 2024, though it remains unclear if the forthcoming report covers just that month or subsequent months as well.

Medicare

• CMS issued its annual Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Proposed Rule for FY 2026 on April 11, 2025. The proposal includes a 2.4% increase in operating payment rates for general acute care hospitals and a 2.6% increase for LTCH standard payment rates, with expected IPPS payment increases of $4 billion. CMS plans to discontinue the low wage index hospital policy following a court order, reduce the labor-related share from 67.6% to 66%, and modify the nursing and allied health payment formula by changing the order of operations for calculating reimbursable net costs. The proposal also announces the reallocation of FTE cap slots from two closed teaching hospitals and increases the uncompensated care payment pool to $7.14 billion for FY 2026, with comments due by June 10, 2025.
• Healthcare providers face potential revenue losses of $80 billion in 2026 due to looming Medicaid cuts, with hospitals at greatest risk if states drop expansion programs. Federal policy changes may include reducing assistance percentages, capping funds, intensifying eligibility requirements, and increasing scrutiny of payments, which could accelerate hospital closures particularly in rural and low-income areas. Healthcare organizations must respond by improving margins, expanding alternative revenue streams, optimizing operations, enhancing care coordination, and strengthening documentation compliance to survive these financial challenges.

Mergers & Acquisitions

• States are rapidly enacting health care transaction review laws that require pre-transaction notification and often approval from state agencies before health care entities can complete mergers, acquisitions, or ownership changes. These laws can be categorized into four types: those amending material change transaction processes, bills seeking disclosure, legislation enhancing antitrust laws, and proposals prohibiting private equity and hedge funds from controlling health care entities. California’s proposals AB 1415 and SB 351 seek to broaden the Office of Health Care Affordability’s review authority over transactions involving management services organizations and reinforce prohibitions against corporate practice of medicine, particularly targeting private equity and hedge funds.

Non-Competes

• Arkansas passed legislation that voids noncompete agreements restricting physicians’ practice within their scope. The law, expected to take effect around July 15, 2025, applies to medical doctors and osteopaths licensed under Arkansas statutes. The Act does not specify whether it will invalidate existing physician noncompete agreements or only apply to future contracts. While physician noncompetes are now prohibited, other restrictive covenants such as non-solicitation agreements, confidentiality agreements, and standard employment terms remain enforceable for physicians in Arkansas.

Pharmacies & Benefit Managers

• The pharmacy industry confronts significant challenges as 29% of retail pharmacies closed between 2010-2021, with closures disproportionately affecting communities serving Medicaid and Medicare patients. Drug shortages persist due to vulnerable supply chains heavily dependent on foreign manufacturing of pharmaceutical ingredients from China and India, which legislative efforts like California’s CalRx initiative and the federal Affordable Drug Manufacturing Act aim to address. President Trump’s February 2025 Executive Order mandates enhanced transparency in drug pricing, requiring agencies to propose new guidelines within 90 days. The pharmacy sector is simultaneously exploring artificial intelligence to improve medication management and patient care, though implementation faces obstacles including high costs, potential lack of human touch, data quality concerns, and ethical considerations around patient information.
• CMS published a final rule requiring Part D pharmacies to enroll in the Medicare Transaction Facilitator Data Module to facilitate the Medicare Drug Price Negotiation Program established by the Inflation Reduction Act. The Data Module will help manufacturers verify eligibility and accelerate retrospective refunds to pharmacies for the ten negotiated drug products in 2026, while an optional Payment Module will facilitate fund transfers and manage claims revisions. Enrollment begins in June 2025 after the rule takes effect on June 3, with chain pharmacies able to enroll through one centralized submission and dispensing entities permitted to use Pharmacy Service Administrative Organizations to receive Maximum Fair Price refunds.
• In a federal court ruling, Tennessee’s “any willing pharmacy” law was deemed preempted by ERISA because it impermissibly affected plan structure rather than merely regulating costs. The McKee decision aligns with the Tenth Circuit’s ruling in PCMA v. Mulready, which invalidated Oklahoma’s law requiring PBMs to follow certain pharmacy network standards. Courts have consistently held that while states can regulate PBM reimbursement rates, they cannot interfere with plan operation or network design. Self-funded group health plans currently face conflicting state PBM laws across multiple jurisdictions, creating a regulatory challenge that requires resolution by either the Supreme Court or Congress.

Ransomware

• Three healthcare organizations—DaVita, Bell Ambulance, and Alabama Ophthalmology Associates—recently suffered ransomware attacks that compromised sensitive patient data including names, Social Security numbers, and medical information. The Bell Ambulance attack affected 114,000 individuals while the Alabama Ophthalmology Associates breach impacted 131,576 people, with different ransomware groups claiming responsibility for each attack. Healthcare organizations remain prime targets for cybercriminals due to the sensitive nature of patient data, with ransomware attacks against the sector increasing 300% since 2015 according to Microsoft. Security experts recommend focusing on basic security measures like strong passwords, multifactor authentication, and properly segmented networks to protect healthcare systems from these threats.
• The U.S. Department of Health and Human Services Office for Civil Rights has reached a settlement with Comprehensive Neurology regarding a HIPAA Security Rule violation following a ransomware attack. The December 2020 breach compromised the protected health information of 6,800 individuals, including names, clinical information, insurance details, and Social Security numbers. OCR’s investigation determined that the neurology practice failed to conduct a thorough risk analysis of potential vulnerabilities to electronic protected health information. Under the settlement terms, Comprehensive Neurology must implement a corrective action plan monitored for two years and paid $25,000 to OCR, marking the agency’s 12th ransomware enforcement action and 8th enforcement action in its Risk Analysis Initiative.

AI in Healthcare

• A recent survey found that healthcare professionals expect AI to have the greatest impact on administrative tasks (52.4%), followed by EHR management (47.6%) and diagnostic accuracy (41.9%). The survey of 105 professionals across 73 U.S. healthcare organizations revealed that 81.6% of physicians and 78.8% of administrators are eager to adopt AI tools to address workforce shortages and burnout. Nearly 64.8% of respondents view AI as critical for reducing workloads, while 37.1% believe it will improve decision-making in precision medicine, diagnostics, and treatment planning through real-time data insights.
• The National Academy of Medicine released a report comparing generative AI with conventional predictive AI in healthcare. The 15-page publication examines five key differences between these technologies: output evaluation methods, bias manifestation patterns, performance degradation characteristics, societal impacts, and compliance considerations. While predictive AI produces quantitative predictions with straightforward performance metrics, generative AI creates subjective content requiring monitoring for coherence and factual accuracy. The report also introduces a 4-point responsibility matrix categorizing stakeholders as “informed,” “consulted,” “accountable,” or “responsible” to guide implementation in clinical decision-making, administrative efficiency, and patient engagement contexts.

Antitrust

• States are requiring more premerger filings by enacting “baby-HSR” laws modeled after the federal Hart-Scott-Rodino Act, with Washington becoming the first state to expand beyond healthcare to cover all industries. Washington’s law requires parties to submit HSR filings to the state Attorney General if they have their principal place of business in Washington or if in-state annual sales exceed 20% of the HSR filing threshold ($126.4 million). Several other states including California, Colorado, Hawaii, Nevada, Utah, West Virginia, and DC have introduced similar legislation based on the Uniform Premerger Notification Act, while fifteen states already have laws requiring pre-transaction notification for healthcare-related mergers and acquisitions. State attorneys general are increasingly active in merger enforcement, with the National Association of Attorneys General Antitrust Committee chair warning companies to ignore state AGs “at your own peril.”
• A federal jury convicted a man for conspiring to fix wages for Las Vegas home healthcare nurses between 2016-2019 and for fraudulently concealing the investigation during his company’s sale. This marks the Department of Justice’s first antitrust jury conviction since announcing in 2016 that wage-fixing and no-poach agreements would be prosecuted criminally rather than civilly. The conviction follows three previous unsuccessful DOJ prosecutions in similar cases where juries declined to find illegal agreements. The DOJ reiterated in January 2025 that felony criminal charges remain appropriate for agreements affecting worker recruitment or wage terms.

Capital Assets

• Healthcare equipment leases come in two main types: operating leases (short-term agreements lasting 1-5 years with lower monthly payments) and capital leases (10-20 year agreements with purchase options). Healthcare organizations can benefit from leasing through improved cash flow management, avoiding large upfront costs, and gaining tax advantages as operating leases allow for interest and depreciation deductions. Leasing provides flexibility to upgrade equipment as technology evolves, with 60% of healthcare institutions reporting a 15% increase in equipment expenses over the past two years. Understanding lease structures, fair market value, and residual values helps healthcare organizations make informed decisions about equipment acquisition.

Data Privacy

• Three healthcare organizations reported data breaches affecting thousands of patients in recent months. Central Texas Pediatric Orthopedics experienced a network server hack on March 3, 2025, compromising personal and medical information of 140,000 patients, with the Qilin ransomware group claiming responsibility. Omni Healthcare Financial Holdings reported unauthorized network access between January 18-19, 2024, affecting 16,701 individuals, but only completed notifications on April 9, 2025, fifteen months after the breach. Community Dental Care in Minnesota discovered unauthorized access to their network on December 20, 2024, with confirmation on March 24, 2025 that names, addresses, Social Security numbers, and medical information were exposed, though the total number of affected individuals remains unclear.
• Six current and former employees have filed a class action lawsuit against University of Maryland Medical System Corporation and University of Maryland Medical Center. Former UMMC pharmacist Matthew Bathula allegedly installed keylogging software on approximately 400 hospital devices over a decade, obtaining credentials of at least 80 staff members and using them to access victims’ personal accounts, webcams, and home security cameras. The lawsuit claims UMMC had inadequate security that enabled Bathula to target primarily young female medical professionals, recording them in private moments including breastfeeding and intimate activities. After terminating Bathula, UMMC replaced compromised computers and implemented additional cybersecurity controls, but the lawsuit alleges the hospital was aware of potential hacking for years without identifying the perpetrator.
• Data privacy and data security represent distinct concepts that organizations often mistakenly treat as interchangeable. Data privacy focuses on individual control over personal information and regulatory compliance with laws like GDPR and HIPAA, while data security involves technical protections against unauthorized access through measures like encryption and fraud detection. The DOGE incident, where unauthorized access was gained to Treasury Department records, demonstrates how compliance with privacy regulations does not guarantee security from breaches. Organizations must establish separate teams with clear responsibilities—privacy oversight by compliance teams and security management by IT security professionals—to prevent vulnerabilities. Companies that fail to distinguish between these concepts risk regulatory penalties, consumer distrust, operational disruptions, and financial losses from both privacy violations and security breaches.

Equity

• Health care entities managed or funded by HHS face approaching deadlines for Section 1557 compliance, with requirements to review decision-making tools for bias, adopt new policies, and train employees by May 1, 2025, while providers receiving only Medicare Part B funds have until May 6. By July 5, 2025, covered entities must distribute notices about non-English assistance availability, replacing previous foreign language taglines. The enforcement outlook remains uncertain as key components of these regulations conflict with the current administration’s policy goals, particularly regarding transgender protections and foreign language assistance requirements, following executive orders that established English as the official U.S. language.

Fraud & Abuse

• The Seventh Circuit Court of Appeals overturned a landmark Anti-Kickback Statute conviction. Mark Sorensen, the owner of SyMed Inc., had been sentenced to 42 months in prison for allegedly paying kickbacks to marketing firms, a DME manufacturer, and a billing company in connection with Medicare-billed orthopedic braces. The appellate court ruled that Sorensen’s payments did not violate the law because there was insufficient evidence that any recipients influenced healthcare decisions, noting that 80% of prescriptions were rejected by physicians who maintained independent decision-making authority. This ruling clarifies that marketing recommendations are not necessarily illegal referrals and that percentage-based compensation structures are not automatically unlawful under the Anti-Kickback Statute.

Laboratories

• Recent False Claims Act litigation demonstrates critical compliance risks for medical laboratories. In Jensen ex rel. United States of America v. Genesis Laboratory, the court dismissed qui tam claims that Genesis submitted false claims to Medicare for unnecessary tests and violated the Anti-Kickback Statute by waiving copayments to induce referrals, citing insufficient evidence. The takeaway is that laboratories must exercise independent judgment on medical necessity despite physician certifications, ensure requisition forms comply with Medicare regulations, review copayment waiver policies, and maintain documentation of compliance efforts. Laboratories should implement robust compliance programs, provide staff training, document processes thoroughly, and consult legal counsel to mitigate regulatory risks.

Medicare

• CMS issued the fiscal year 2026 Medicare Hospital Inpatient Prospective Payment System proposed rule on April 11, 2025, with comments due by June 10, 2025. The rule proposes a 2.4% increase in operating payment rates for qualifying acute care hospitals, creates several new MS-DRG categories while deleting others, and increases uncompensated care payments to $7.29 billion for FY 2026. Special rural designations including the Medicare-dependent hospital program and low-volume hospital payment adjustment are set to expire on September 30, 2025, with hospitals previously qualifying for MDH status to be paid based on the federal rate thereafter. The rule also proposes updates to the Transforming Episode Accountability Model, which will begin as a five-year mandatory model on January 1, 2026.
• The Trump administration released two final regulatory documents for Medicare Advantage (MA) for 2026, with CMS finalizing a basic payment update of +5.06% that will increase MA payments by $25 billion. CMS did not finalize proposals to expand coverage of anti-obesity medications or implement health equity requirements for utilization management policies, but did codify IRA provisions requiring $0 cost sharing for ACIP-recommended vaccines and $35 monthly caps for insulin. The final rule also includes provisions for Dual Eligible Special Needs Plans, inpatient setting protections, and guardrails for supplemental benefits, while the new risk model will be fully implemented in 2026, saving Medicare trust funds approximately $13 billion.

Pharmacy Benefit Managers

• Arlington-based Texas Health Resources is suing six drugmakers and pharmacy benefit managers, alleging they colluded to raise insulin prices by up to 1,000% over two decades while collecting secret rebates and fees. The nonprofit system filed the federal lawsuit on March 26 in New Jersey District Court against Express Scripts, CVS Caremark, Optum Rx, Sanofi, Eli Lilly, and Novo Nordisk, claiming violations of the RICO Act and Texas consumer protection laws. Texas Health Resources, which covers about 40,000 beneficiaries through its self-funded insurance plan, joins more than 400 other entities that have filed similar lawsuits against these companies. All defendants have denied the allegations, with CVS Caremark, Sanofi, Novo Nordisk, Optum Rx, and Eli Lilly each issuing statements calling the lawsuit baseless or meritless and defending their pricing practices.

Private Equity

• Texas’ Corporate Practice of Medicine doctrine prohibits corporations and non-physicians from practicing medicine or employing physicians to provide medical services. Private equity firms use Management Service Organization models to invest in healthcare while attempting to comply with CPOM restrictions, but many management service agreements contain provisions that transfer excessive control to non-physician entities. Courts have identified several red flags that indicate CPOM violations, including excessive fee structures, control over medical personnel, financial control, influence over clinical decision-making, and restrictive clauses that limit physicians’ ability to terminate relationships. Contracts that violate the CPOM doctrine are likely unenforceable under Texas law, giving physicians potential legal grounds to terminate problematic MSO relationships without penalty.ata Privacy
• Three healthcare organizations reported data breaches affecting thousands of patients in recent months. Central Texas Pediatric Orthopedics experienced a network server hack on March 3, 2025, compromising personal and medical information of 140,000 patients, with the Qilin ransomware group claiming responsibility. Omni Healthcare Financial Holdings reported unauthorized network access between January 18-19, 2024, affecting 16,701 individuals, but only completed notifications on April 9, 2025, fifteen months after the breach. Community Dental Care in Minnesota discovered unauthorized access to their network on December 20, 2024, with confirmation on March 24, 2025 that names, addresses, Social Security numbers, and medical information were exposed, though the total number of affected individuals remains unclear.

Ransomware

• Ransomware group Qilin posted 42 gigabytes of data stolen from Central Texas Pediatric Orthopedics on the dark web in February, with the practice now notifying 140,121 affected individuals. The unauthorized access occurred between January 23-26, 2025, compromising patient information including names, government IDs, medical data, insurance details, birth dates, and X-ray images of minors. CTPO has reported the breach to the FBI and implemented security enhancements including endpoint detection software, password resets, and server rebuilding. Experts warn that pediatric healthcare records are particularly valuable targets due to children’s pristine credit histories, with several law firms already investigating the incident for potential class action litigation.

Reimbursement

• An estimated 450 million medical claims are denied annually in the US, with Texas having a 22% denial rate for in-network ACA claims. The American Medical Association reports that AI tools used by insurers can produce denial rates up to 16 times higher than typical. The Texas Senate has advanced bill SB 815 to restrict insurers from using AI for claim decisions, while new AI platforms like Claimable and Fight Health Insurance have emerged to help patients appeal denials. These AI appeal tools aim to level the playing field against insurers who have established an early advantage in using technology for claims processing.

Skilled Nursing Facilities

• CMS has extended the deadline for Skilled Nursing Facilities (SNFs) to submit Medicare revalidations to August 1, 2025, following a previous extension from the original deadline to May 1, 2025. The extension comes as AHCA/NACL reports less than 20% of SNFs had submitted applications by mid-March, with many applications being returned with requests for additional information. The revalidation process now includes Attachment 1, which collects new categories of information on ownership, management, organization, and administration. CMS updated its guidance on April 9, 2025, with additions to Section IV and FAQs regarding requirements for reporting Additional Disclosable Parties.

OIG Advisory Opinion No. 25-02

Favorable opinion regarding an arrangement whereby Requestor— designated as a community health center pursuant to Section 330 of the Public Health Service Act—proposes, during the provision of certain social services to individuals, to: (1) identify individuals in need of primary care services; (2) inform them of the availability of such services; and (3) schedule an appointment for them to receive primary care services from Requestor or refer them to a local primary care provider.

🔍 What’s the Issue?

A federally designated Community Health Center (the “Requestor”) asked the Office of Inspector General (OIG) if it could legally do the following as part of its community outreach:

1. Identify individuals in need of primary care during their visits for social services (like childcare, food, or safety support).
2. Inform them about available primary care providers.
3. Help them schedule appointments—either with the Health Center itself or another local provider.

They wanted to make sure this setup wouldn’t violate federal anti-kickback laws or other rules meant to prevent improper patient referrals.

🏥 Background on the Health Center

• Offers free or low-cost medical and social services to underserved communities.
• Also gives out non-healthcare goods, like diapers, books, and help for crime victims.
• Many people come for the social services but don’t realize they can also get affordable medical care there.

⚖️  Legal Concerns

two key laws at play:

1. Anti-Kickback Statute – Prohibits giving something of value to induce someone to use federally funded healthcare services.
2. Beneficiary Inducements CMP – Prohibits offering free stuff to patients to influence their choice of healthcare provider.

✅  OIG’s Conclusion: Allowable with conditions

OIG said they will not impose penalties because:

• The Health Center does not push patients to choose them—they provide a neutral list of providers in alphabetical order.
• Other providers can be included on the list (“any willing provider” rule).
• People can still get social services even if they don’t want or need healthcare.
• The goal is to connect underserved people with care they might otherwise skip due to cost or confusion.

OIG found the setup aligns with the Health Center’s mission to help underserved populations and isn’t a scheme to inappropriately gain more patients.

🚦 Bottom Line

The arrangement is legally allowable as long as it’s carried out fairly and transparently. The Health Center must stick to the safeguards they promised—neutral lists, no pressure to choose them, and full freedom for individuals to pick any provider or none at all.

Data Privacy

• A dental management firm is notifying 173,400 people across six states about an email hack that exposed sensitive information including names, Social Security numbers, and medical data. The Nashville-based firm, which provides HR and finance services to 60 dental practices and 10 group practices, faces at least four federal class action lawsuits alleging negligence in safeguarding patient information. The breach was discovered on September 11, 2024, when suspicious activity was detected in an employee’s email account, making it the largest of three major dental-related data breaches reported in 2025. In 2024, about two dozen dental practice breaches affected more than 1.2 million individuals, highlighting the sector’s vulnerability to cyberattacks.
• HIPAA compliance faces significant changes in 2025 as HHS implements new security measures following a 264% increase in ransomware attacks in 2024. The Office for Civil Rights is enforcing stricter security risk analysis requirements while proposing updates to the HIPAA Security Rule that would mandate technical improvements like encryption and multifactor authentication. Patient access rights remain a priority with multiple enforcement actions in 2024-2025, alongside new information blocking rules effective December 2024. Additionally, HHS issued a final rule protecting reproductive health care information privacy in December 2024, though this faces legal challenges from Texas in federal court.

False Claims Act

• A Fifth Circuit Judge has questioned the constitutionality of the False Claims Act’s qui tam provision in a concurring opinion in United States ex rel Montcrief v. Peripheral Vascular Assocs., P.A. Justice Duncan argues the provision violates the Appointments Clause by allowing private citizens to exercise executive branch power without proper appointment, echoing a 2024 ruling by Florida District Judge Kathryn Mizelle in United States ex rel. Zafirov v. Fla. Med. Assocs., LLC. Both judges cite Justice Clarence Thomas’s dissent in Polansky, which contends that Congress cannot authorize private relators to represent United States interests in civil litigation. The Fifth Circuit remanded a $28.7 million Medicare fraud judgment against PVA while Duncan noted that when the government declines to intervene in qui tam cases, private relators exercise government power without executive branch oversight.

Medicare Reimbursement

• A new Medicare policy aims to combat fraud in the skin substitutes market where spending quadrupled in four years, costing taxpayers nearly $10 billion annually. The Local Coverage Determination (LCD) ensures Medicare only covers treatments with clinical evidence while maintaining access to over a dozen proven skin substitutes. The policy targets companies that exploited loopholes to generate nine-figure revenues without research or FDA review, and will take effect April 13, 2025. Medicare Administrative Contractors implemented this measure to proactively prevent fraud rather than relying on lengthy investigations after damage is done.

Mergers & Acquisitions

• The U.S. Department of Health and Human Services is closing six of its ten Office of the General Counsel regional offices and reducing its workforce by 20,000 employees. This consolidation will likely cause disruptions to Change of Ownership approvals needed for healthcare mergers and acquisitions, as well as delays in enforcement actions and compliance determinations. The four remaining OGC offices will redistribute workload across larger geographic areas, potentially resulting in loss of localized expertise and creating challenges for Medicare contractors. Healthcare investors and providers are advised to consult with experienced attorneys to navigate these changes and minimize transaction disruptions.
• The Texas House of Representatives introduced House Bill 2747, requiring health care entities to provide 90-day advance notice to the Texas Attorney General for transactions resulting in material ownership, operations, or governance changes. The bill, which would take effect September 1, 2025 if passed, applies to a broad range of health care entities including providers, facilities, provider organizations, and pharmacy benefit managers. The legislation grants the Texas Attorney General power to conduct market studies on health care market conditions and transaction impacts, with violations potentially resulting in a $10,000 civil penalty. Texas joins numerous states implementing increased oversight of health care transactions, with common focus on competition, market concentration, and care quality.

Antitrust

• The Department of Justice announced the formation of an Anticompetitive Regulations Task Force aimed at eliminating state and federal laws that undermine market competition. The Task Force will focus on five key sectors: housing, transportation, food and agriculture, healthcare, and energy, while taking a whole-of-government approach with attorneys and economists from across the Antitrust Division and other agencies. Public comments will be accepted until May 26, 2025, to help identify problematic regulations, with the initiative following a similar effort from the first Trump administration in 2018. Questions remain about the Task Force’s jurisdiction over state laws and regulations, particularly regarding the state action immunity doctrine that protects state and local governments from federal antitrust claims.

Compliance, Audits, and Enforcement

• Healthcare experts emphasize that proper documentation and regular internal audits are essential for medical billing compliance. Medical billers, coders, and nurse reviewers provide critical services including medical record reviews, billing analysis, and assessment of treatment appropriateness for healthcare providers, attorneys, and insurance companies. Healthcare providers remain responsible for billing accuracy even when using third-party billing services, making practice managers with compliance expertise a valuable investment that can prevent claim denials and expand revenue. In litigation contexts, these specialists can identify billing discrepancies, evaluate standard of care, and help establish links between injuries and medical events, transforming what begins as malpractice cases into fraud investigations when necessary.
• The Office of Inspector General (OIG) recently released a report identifying 287 audit issues across all twelve Medicare Administrative Contractor (MAC) jurisdictions during fiscal years 2019-2021, with each jurisdiction failing to meet the 95% performance threshold for Review and Audit Quality standards in at least one year. The report categorized issues into five areas: improper reviews, inadequate oversight of medical education reimbursement, improper review of cost allocations, improper calculations for nursing programs, and inadequate review of bad debts. OIG recommended that CMS provide MACs with better explanations of evaluation results, update audit programs with revised requirements, and offer additional training, to which CMS responded that it already meets weekly with MACs and is working to incorporate updated guidance into audit programs.
• President Trump issued an Executive Order on February 25, 2025 to strengthen enforcement of healthcare price transparency regulations, building upon a 2019 order and rooted in the Affordable Care Act’s 2010 amendments. A 2024 audit revealed only 46 percent of hospitals were compliant with transparency rules, with penalties ranging from $300 to $5,500 per day depending on hospital capacity. Healthcare organizations face increased risks including administrative penalties, civil enforcement actions, and potential criminal liability, prompting recommendations for internal audits, enhanced compliance programs, legal counsel engagement, and robust reporting mechanisms.

Cybersecurity and Data Protection

• Biosensors in healthcare face complex regulatory challenges across different regions, with the FDA in the US using a three-tier risk classification system while the EU implements stricter Medical Device and In Vitro Diagnostic Regulations. Data security remains problematic with 40% of FDA-approved wearables lacking robust encryption, while ethical concerns persist regarding data ownership and privacy, exemplified by a study showing 60% of diabetes apps sell user data without clear consent. Technological innovation outpaces regulatory frameworks, creating validation bottlenecks for startups and highlighting the need for global harmonization, as only 15 countries have adopted the WHO’s Global Model Regulatory Framework. Market access varies significantly between countries, with reimbursement policies and affordability creating barriers to equitable distribution of biosensor technology.
• Data privacy is a major concern when implementing AI in managed care pharmacy, particularly regarding how HIPAA-protected information interacts with large language models. Current expectations suggest liability for AI errors will primarily fall on healthcare providers rather than vendors, though this model could evolve as the technology develops. Organizations cannot guarantee AI systems are completely free from bias, making continuous data review and human oversight essential. Colborn recommends that organizations establish clear frameworks for AI use, disclose which entities receive patient data, and commit to rigorous oversight to address patient concerns.
• According to CIO’s 2024 Security Priorities study, 40% of tech leaders prioritize strengthening confidential data protection as organizations implement comprehensive security frameworks including encryption, Zero Trust Architecture, and multi-factor authentication to combat cyber threats. Security experts recommend data governance frameworks with clear standards for quality, accuracy, and relevance, alongside Master Data Management to create a single source of truth for critical business entities. Organizations must address human error through regular cybersecurity training, simulated threats, and interactive awareness programs to transform employees into a strong defense line. AI technologies are being deployed to detect and mitigate cyber threats in real time while also optimizing operations through intelligent automation and enabling personalized customer experiences.

Drug Regulation

• The popularity of GLP-1 drugs for weight loss and diabetes has triggered multiple litigation fronts in the U.S.. FDA drug shortages led to legal battles between brand manufacturers and compounding pharmacies, with recent cases challenging FDA decisions to remove drugs like tirzepatide and semaglutide from shortage lists. Patent litigation follows the Hatch-Waxman framework with varying timelines based on FDA exclusivity periods – liraglutide’s first generic was approved in December 2024, semaglutide faces ongoing patent challenges through 2025, and tirzepatide’s exclusivity extends to 2027. The International Trade Commission provides another venue for enforcement, with Eli Lilly pursuing action against online pharmacies selling compounded tirzepatide, potentially resulting in import bans.
• The Eastern District of Texas vacated the FDA’s Laboratory Developed Test (LDT) Final Rule, ruling in favor of laboratory plaintiffs who argued that LDTs are services rather than devices under the Federal Food, Drug and Cosmetic Act. The court determined that LDTs are “proprietary methodologies” outside FDA jurisdiction, as the agency can only regulate tangible goods like test kits, not professional medical services. The ruling establishes that Congress gave the Centers for Medicare and Medicaid Services authority to regulate clinical laboratories and their tests under the Clinical Laboratory Improvements Act, not the FDA. The decision prevents nearly 80,000 existing LDTs and over 1,100 laboratories from falling under FDA’s regulatory framework that was scheduled to take effect in May 2025.

Medical Malpractice

• While AI can reduce medical errors, experts debate who bears liability when AI-assisted healthcare goes wrong. The Federation of State Medical Boards recommends holding clinicians responsible for AI errors, not technology creators, with 3 in 5 physicians now using AI in their practice. Medical liability insurer Indigo believes AI will ultimately reduce malpractice rates, though legal experts note there’s no clear framework for determining fault in AI-related medical mistakes. Healthcare organizations are urged to establish AI usage guidelines for staff, as clinicians face challenges verifying AI recommendations amid time constraints and staffing shortages.

Mergers & Acquisitions

• The physician practice M&A market is experiencing a revival with pharmaceutical companies, pharmaceutical services providers, and insurers emerging as strategic buyers in the physician practice management space. Despite headwinds including regulatory pressure, macroeconomic challenges, and operational difficulties, major transactions have occurred such as Cencora’s $4.6 billion acquisition of Retina Consultants of America and Cardinal Health’s $2.8 billion stake in GI Alliance. Strategic buyers pursue these acquisitions to diversify their businesses, achieve vertical integration, and gain control over care delivery, with future consolidation likely driven by buyers with available capital and interest in diversification.

Veterinary Medicine and Telehealth

• A Texas State Senator has proposed legislation to expand telehealth practices to veterinary medicine, which would update Texas law to allow veterinarians to establish client-patient relationships electronically without requiring initial physical examinations. The Texas Veterinary Medical Association opposes the bill, warning that serious conditions could be misdiagnosed without physical examinations, potentially threatening animal health and the state’s $15 billion animal agriculture industry. Supporters argue telehealth would benefit rural areas with limited veterinary access.

Abortion

• Senate Bill 31, known as the Life of the Mother Act, aims to clarify medical exceptions to Texas abortion laws that currently permit the procedure only when the mother’s life or major bodily function is at risk. The bill would specify that doctors need not delay treatment if doing so increases risk to the pregnant woman, broadens definitions for ectopic pregnancy and premature water breaks, and protects physician-patient discussions about abortion options from being considered “aiding and abetting.” With bipartisan support including 12 Republican senators and Lt. Gov. Dan Patrick’s backing, the legislation would require the Texas Medical Board to offer educational courses about physicians’ rights under the law. Texas doctors have reported confusion about existing laws, with 29% lacking clear understanding of abortion regulations, leading to delayed care and increased complications for pregnant women.

Artificial Intelligence

• Healthcare organizations implementing LLMs face eight critical challenges including over-reliance on AI without domain expertise integration, unresolved data quality issues across fragmented systems, and ethical risks in handling sensitive healthcare data. Additional pitfalls include poor workflow integration, inadequate model validation post-deployment, neglect of regulatory requirements, overpromising AI capabilities to stakeholders, and failure to customize models for specific healthcare needs. Healthcare companies must maintain human expertise in the loop, implement robust data governance, ensure regulatory compliance, and set realistic expectations to successfully deploy LLMs that enhance rather than compromise patient care and operational efficiency.

Compliance Programs & Audits

• Compliance auditing has become mandatory in today’s regulatory environment, with federal and state laws requiring companies to conduct regular reviews of their practices. The Office of Inspector General’s Compliance Program Guidance identifies auditing as a core element that helps organizations detect fraud, assess policy adherence, and mitigate risks before they escalate into enforcement actions. Recent settlements demonstrate the consequences of inadequate compliance monitoring, with companies like Pfizer, Teva, Innovasis, and Endo Health Solutions paying millions or billions in penalties for violations related to kickbacks, improper marketing, and other infractions. Companies should prioritize auditing high-risk areas including speaker programs, healthcare professional arrangements, promotional materials, and patient assistance programs using a risk-based approach.

Contracting

• Healthcare AI vendor contracts require thorough pre-negotiation preparation, including comprehensive risk assessment and stakeholder engagement. Organizations must evaluate AI tools within a governance framework using resources like HEAT maps and the NIST AI Risk Management Framework to categorize risks. Contract negotiations should address data rights, with customers seeking ownership of inputs and outputs while vendors aim to retain rights to their services and products. Key contract provisions include privacy, security, regulatory compliance, indemnification, and liability limitations, with special attention to HIPAA compliance when patient health information is involved.

Cybersecurity & Privacy

• Healthcare cyberattacks have increased dramatically, with annual large breaches nearly tripling from 242 (2010-2014) to 713 (2020-2024), with 81% caused by hacking or IT incidents in 2024 alone. The 2024 Change Healthcare breach affected 190 million individuals, making it the largest healthcare data breach to date. When protected health information is compromised, organizations must notify affected individuals, media outlets, state agencies, and the Office for Civil Rights, potentially facing investigations, enforcement actions, and costly settlements. Healthcare entities must strengthen defenses through annual security risk assessments, multi-factor authentication, and comprehensive incident response plans, with HHS proposing updates to the HIPAA Security Rule to mandate these protective measures.
• [The Office for Civil Rights has announced a $3 million settlement with Solara Medical Supplies for HIPAA violations](HHS Settles HIPAA Security Breach Stemming from Phishing Cyberattack for $3 Million). A phishing attack compromised eight employee email accounts, exposing protected health information of over 100,000 individuals, followed by a second breach when notification letters were sent to incorrect addresses affecting 1,500 more people. OCR investigation determined Solara failed to conduct proper risk analysis, implement adequate security measures, and notify affected parties in a timely manner. The settlement includes a corrective action plan requiring risk analysis, implementation of a risk management plan, policy development, and staff training on HIPAA compliance.
• The Seventh Circuit ruled in Hulce v. Zipongo that communications promoting free services do not qualify as “telephone solicitations” under the TCPA. Plaintiff Hulce received approximately 20 calls and texts from Foodsmart about services available at no cost through his healthcare plan, with payment coming from the insurer rather than Hulce. Foodsmart successfully argued that since their communications encouraged use of free services rather than purchase of services, they fell outside the TCPA’s definition of solicitation. The court determined that encouraging use of a service available at no cost to the recipient does not constitute encouraging a purchase, even when a third party pays for the service.

Fraud & Abuse

• A federal court in the Northern District of Texas ruled that False Claims Act penalties totaling $299-449 million would violate the Constitution’s Eighth Amendment Excessive Fines Clause. The case involved Healthcare Associates of Texas, found liable for $2.7 million in damages across 21,844 false Medicare claims averaging $126.06 each. Instead of applying the statutory penalty range of $13,946 to $27,894 per false claim, the court imposed penalties equal to the trebled damages, resulting in a $16 million judgment. This ruling establishes a precedent for FCA defendants to invoke constitutional protections against disproportionate penalties.
• A bipartisan congressional proposal aims to combat healthcare fraud by requiring states to check Social Security Death Master Files to prevent deceased physicians’ identifiers from being misused. The proposal comes amid increased scrutiny of Medicare and Medicaid programs, with Colorado reportedly paying $7.3 million to insurance companies for deceased recipients and California facing a $9.5 billion Medi-Cal price tag that exceeded initial estimates. According to the Government Accountability Office, improper payments totaled $54.3 billion for Medicare and $31.1 billion for Medicaid in fiscal year 2024.

GLP-1 Weight Loss Drugs

• The FDA has removed popular GLP-1 weight-loss drugs from its shortage list, with semaglutide (Ozempic/Wegovy) removed on February 21, 2025, and tirzepatide (Mounjaro/Zepbound) on December 19, 2024. This removal means compounding pharmacies must cease producing copies of these medications, with specific deadlines: immediate cessation for tirzepatide under section 503A, March 19, 2025 for tirzepatide under section 503B, April 22, 2025 for semaglutide under 503A, and May 22, 2025 for semaglutide under 503B. The Outsourcing Facilities Association challenged the FDA’s decision in court but lost when the court ruled that requiring notice before removing drugs from the shortage list would prevent the FDA from maintaining an “up-to-date” list as mandated by Congress.

Health and Human Services

• The Department of Health and Human Services plans to cut 10,000 full-time jobs as part of a larger reduction that will decrease total headcount by 20,000 employees, saving $1.8 billion annually according to HHS. The cuts will affect multiple agencies including 3,500 workers at FDA, 2,400 at CDC, 1,200 at NIH, and 300 at CMS, though HHS claims the reductions will not impact core services like Medicare, Medicaid, or food and drug reviews. The reorganization includes consolidating 28 redundant offices into 15 new divisions, reducing regional offices from 10 to five, and creating new entities like the Administration for a Healthy America, which will combine multiple existing health offices. Democratic lawmakers and health advocates have criticized the cuts, warning they could harm vulnerable populations and disrupt essential services.

Immigration

• Hospitals and healthcare systems nationwide are experiencing increased random inspections by USCIS targeting H-1B visa holders. Immigration officers from the Fraud Detection and National Security Directorate conduct unannounced site visits to verify compliance with H-1B program requirements, focusing on Public Access Files, work location accuracy, and position/salary verification. Non-compliance can result in fines, program debarment, operational disruption, and reputation damage. Healthcare facilities are advised to conduct system-wide compliance reviews, train staff on inspection protocols, collaborate with immigration counsel, standardize recordkeeping, and stay informed about policy changes to maintain compliance.

Taxation

• Continuing Care Retirement Communities (CCRCs) provide comprehensive senior care from independent living to skilled nursing, with entrance fees averaging $400,000 and monthly fees around $3,450. Residents can deduct portions of these fees as medical expenses on their taxes if their total medical costs exceed 7.5% of their adjusted gross income. The deductible percentage varies by facility and is calculated based on the community’s aggregate healthcare costs, not individual usage. This tax benefit applies from day one of residency regardless of current healthcare needs and requires itemizing deductions on Schedule A of Form 1040. Alternative senior living arrangements like assisted living facilities and home modifications may also qualify for similar tax advantages if they meet IRS criteria for medical necessity.

Telehealth

• The DEA has further delayed the effective dates of two telemedicine prescribing rules until December 31, 2025. The rules would expand prescribing of buprenorphine for opioid use disorder and controlled substances for VA patients via telemedicine. Originally scheduled to become effective February 18, 2025, then delayed to March 21, 2025, the Department of Justice now seeks additional time to review questions of fact, law, and policy despite some commenters requesting immediate implementation. Meanwhile, practitioners can continue prescribing controlled medications via telemedicine without prior in-person visits under COVID-19 flexibilities through the end of 2025.

Texas Health and Human Services Commission

• An OIG audit found that the Texas Health and Human Services Commission failed to comply with federal and state requirements in overseeing Day Activity and Health Services facilities. The investigation revealed 253 instances of noncompliance across 20 audited providers, with 19 facilities violating health and safety requirements and 19 failing to meet administrative standards. OIG recommended that Texas correct these violations, enhance oversight of providers, and help facilities improve their operations. Texas has agreed with all recommendations and outlined plans to address the issues.

Transparency

• Healthcare price transparency laws implemented since 2021 require hospitals and health plans to publish pricing information online and prohibit gag clauses that restrict sharing of cost and claims data. The Consolidated Appropriations Act of 2021 codified these prohibitions, requiring annual attestation of compliance through the Gag Clause Prohibition Compliance Attestation process, with the first submission deadline on December 31, 2023. Healthcare providers can leverage these regulations by requesting comprehensive pricing data, benchmarking against competitors, and highlighting value metrics to negotiate better reimbursement rates with payers. Despite these regulatory advances, challenges remain including limited enforcement, complex data formats, and the need for stricter penalties to ensure compliance from health plans.

Abortion

• Texas Attorney General Ken Paxton announced the arrest of Maria Margarita Rojas, a 48-year-old midwife who operated multiple clinics in the Houston area. Rojas, known as “Dr. Maria,” was charged with performing illegal abortions and practicing medicine without a license, both serious offenses under Texas law. Her network included three clinics—in Waller, Cypress, and Spring—where unlicensed individuals allegedly posed as medical professionals. The Attorney General’s office has filed for a temporary restraining order to shut down these facilities and may seek civil penalties of at least $100,000 per violation under the Texas Human Life Protection Act of 2021. Texas law specifically holds abortion providers, not patients, criminally responsible for unlawful procedures.
• A second person has been arrested in connection with illegal abortion services at clinics operated by a midwife near Houston. Jose Manuel Cendan Ley, a 29-year-old medical assistant, faces charges of performing an illegal abortion and practicing without a license, while Rojas was previously arrested for operating three clinics that allegedly performed illegal abortion procedures. Texas Attorney General Ken Paxton announced that Rubildo Labanino Matos was also arrested for practicing medicine without a license in connection to the investigation. Texas law bans abortion at all stages of pregnancy with exceptions only for life-threatening conditions, with those convicted of performing illegal abortions facing up to 20 years in prison. This case represents the first criminal charges filed under Texas’s near-total abortion ban.

AI in Healthcare

• AI healthcare models trained on limited institutional data face challenges in broader applications. Healthcare institutions currently train AI models using data from their own populations, creating systems that work well locally but fail when deployed in different settings due to variations in practice patterns, genetic factors, and lifestyle differences across regions. The isolation of medical data in institutional silos prevents AI from reaching its potential to standardize and improve healthcare globally. To address this, healthcare organizations must implement cross-institutional data sharing frameworks and ensure AI models are trained on diverse populations. The solution requires collaboration between health systems, regulatory support, and transparent validation processes to create AI models that can be trusted and effective across all healthcare settings.
• A Harvard Medical School study found that an open-source AI model called Llama 3.1 405B performed equally well as GPT-4, a leading proprietary model, in diagnosing complex medical cases. Researchers compared both models on 92 challenging cases from The New England Journal of Medicine, with results published March 14 in JAMA Health Forum. The NIH-funded research was conducted by Harvard Medical School in collaboration with clinicians from Beth Israel Deaconess Medical Center and Brigham and Women’s Hospital. Open-source models offer advantages by allowing hospitals to keep patient data in-house rather than transmitting it to external servers required by closed-source models.
• Google is developing multiple AI healthcare initiatives, including TxGemma for drug discovery, Articulate Medical Intelligence Explorer for patient data collection, and a “co-scientist” chatbot for research assistance. The company has partnered with medical centers like Beth Israel Deaconess in Boston and Princess Maxima Center in the Netherlands, where doctors report tasks that once took days now complete in seconds. Meanwhile, Congress continues to extend pandemic-era telehealth rules through short-term solutions rather than permanent legislation, causing concern among healthcare providers about long-term investment in remote care technologies.
• The FUTURE-AI framework provides international consensus guidelines for developing trustworthy healthcare AI systems through six guiding principles: fairness, universality, traceability, usability, robustness, and explainability. Developed by a consortium of 117 experts from 50 countries over a two-year period, the framework includes 30 detailed recommendations covering the entire AI lifecycle from design to deployment. FUTURE-AI is designed as a dynamic framework that will evolve with technological advancements and stakeholder feedback to ensure AI tools are technically robust, clinically safe, ethically sound, and legally compliant.

Cybersecurity

• HIPAA regulations require healthcare providers and business associates to protect patient information in electronic communications. When communicating PHI to patients via email or text, covered entities must either encrypt the information or warn patients about security risks and obtain their consent to proceed with unsecured communications. For communications from patients, providers can assume email is acceptable if initiated by the patient, though warning about risks is recommended. Communications with other providers or third parties require stricter security measures, as simply warning about risks is insufficient; these messages must comply with Security Rule standards through encryption or other safeguards.
• Healthcare data breaches reached record levels in 2024, with a 9.96% increase from 2023. The healthcare sector ranks second to finance in sensitive data volume, with 68% of medical devices expected to be connected by 2025, creating increased security risks through wireless communication and cloud storage. The industry faces future challenges from quantum computing threats, with NIST developing post-quantum cryptography standards while organizations still struggle with basic security measures like multi-factor authentication.
• A vulnerability in ChatGPT identified last year is being exploited to target healthcare organizations, with 35% of analyzed organizations unprotected due to security misconfigurations. A recent report documented over 10,000 cyberattack attempts in one week, despite the vulnerability being classified as medium severity. The American Hospital Association warns these attacks could lead to data breaches, unauthorized transactions, and regulatory penalties. Healthcare remains the costliest sector for cyberattacks, with the average breach costing nearly $11 million—more than three times the global average.
• The U.S. Department of Health and Human Services’ Office for Civil Rights has reached a $227,816 settlement with Health Fitness Corporation for HIPAA Security Rule violations. The settlement, which marks the fifth enforcement action in OCR’s Risk Analysis Initiative, resolves an investigation triggered by four breach reports filed between October 2018 and January 2019, where electronic protected health information became discoverable online due to a server misconfiguration. Health Fitness failed to conduct a thorough risk analysis until January 2024, affecting approximately 4,304 individuals whose data was exposed beginning in August 2015 but not discovered until June 2018. Under the agreement, Health Fitness must implement a corrective action plan including annual risk analyses, risk management planning, and policy development, which OCR will monitor for two years.

Dentistry

• [The Texas Health and Human Services Commission has adopted an amendment to the Texas Government Code](Adopted Rules Title 25) that requires providers to be reimbursed for teledentistry services. This amendment allows dentists to use synchronous audiovisual technologies to conduct oral evaluations of established clients. As a result, oral evaluations are now more accessible, reducing unnecessary travel for clients in the Texas Health Steps Program.

FDA

• FDA regulations prohibit compounding pharmacies from creating “essentially a copy” of commercially available drugs unless the modification produces a “significant difference” for an individual patient. Adding B12 to name brand weight loss drugs does not automatically exempt them from being considered copies under Sections 503A and 503B of the Federal Food, Drug, and Cosmetic Act. For a compounded drug to be permissible, the prescribing practitioner must document that the modification creates a significant difference for the specific patient. The FDA established these rules to prevent compounders from circumventing regulatory requirements by making minor changes to commercially available medications.

Medicaid

• Medicaid program integrity involves both federal and state responsibilities, with states handling day-to-day administration while the federal government provides support and oversight. There is no comprehensive measure of fraud in Medicaid, though most fraud is committed by providers rather than beneficiaries, with the Health Care Fraud and Abuse Control program recovering $3.4 billion across Medicaid and Medicare in FY 2023. Improper payments, which had a 5.1% rate in 2024, are not equivalent to fraud, as 79.1% resulted from insufficient documentation or administrative errors rather than payments to ineligible recipients. HHS and CMS develop strategies to address program integrity issues, focusing on prevention and early detection rather than just recovery of misspent funds.

Mergers & Acquisitions

• The IRS workforce has reached its lowest level since the 1970s, with outdated systems still relying on fax machines for communications. Healthcare organizations involved in M&A transactions must prepare for extended processing times for tax documents, determination letters, and name changes. The IRS will take longer to process powers of attorney forms, provide guidance on complex issues, and review tax-exempt status applications. State tax-exempt status applications will face delays since they depend on federal approval.
• Texas House Bill 2747, introduced on February 12, 2025, would require healthcare entities to provide 90-day advance notice to the Texas Attorney General for transactions resulting in material changes to ownership, operations, or governance structure. The bill covers six types of material change transactions and applies to a broad range of healthcare entities including providers, facilities, organizations, health carriers, and pharmacy benefit managers. Violations could result in civil penalties up to $10,000 per violation, with the AG authorized to recover penalties, attorney fees, and enjoin entities from violations. Unlike similar requirements in California and Massachusetts, information provided to the AG would remain confidential, only released with consent or to contracted experts for market studies.

Privacy

• HIPAA was designed to balance privacy protections with healthcare efficiency but was never intended as a comprehensive health information privacy law. The healthcare privacy landscape has become increasingly complex due to the explosion of non-HIPAA health data from mobile apps, wearables, and tech platforms that remain largely unregulated. States have created overlapping privacy laws with inconsistent requirements, while the FTC and state attorneys general use general consumer protection authority to fill regulatory gaps. Federal legislation is unlikely to resolve these issues as proposals typically exempt HIPAA-covered entities, potentially creating dual regulatory systems that complicate compliance and impede medical research, public health initiatives, and healthcare innovation.
• Senators have reintroduced the Genomic Data Protection Act (GDPA) to regulate genetic data collected by direct-to-consumer testing companies not covered by HIPAA Rules. The legislation would require these companies to provide consumers with mechanisms to access their genomic data, delete accounts, and request destruction of biological samples. GDPA would mandate clear notices explaining consumer rights, including notification at least 30 days before a company acquisition. The bill aims to establish federal protections while not preempting state laws unless they conflict with GDPA, with non-compliant companies facing penalties under the FTC Act.

Tax Exemption

• [The Fifth Circuit Court of Appeals affirmed that Memorial Hermann Accountable Care Organization does not qualify for tax-exempt status under Section 501(c)(4)](Accountable Care Organization Denied Tax-Exempt Status | Gordon Feinblatt LLC). The court applied the “substantial non-exempt purpose” test, determining that Memorial primarily benefited healthcare providers and insurance companies rather than promoting social welfare. Memorial had argued for the application of the “primary purpose test” from Treasury Regulations, but the court rejected this approach while noting it would have reached the same conclusion under either standard. Though currently binding only in Louisiana, Mississippi, and Texas, the ruling suggests Accountable Care Organizations elsewhere may face similar tax treatment.