Insurance agent Jason Fine says he is helping dozens of clients undo Affordable Care Act health plan switches that were made without their consent. The Government Accountability Office reports that fraud involving unauthorized plan changes and enrollments remains an issue for the Affordable Care Act, despite new CMS rules. The CMS fielded more than 275,000 complaints about unauthorized ACA enrollments and plan switches in 2024, and the GAO estimates that about 1.5% of ACA enrollments are fraudulent. Congress is divided about how to address the matter.

Next Bio-Research Services, which does business as Next Molecular Analytics, will resolve illegal kickback accusations for $758,000. The Justice Department said that the lab, based in Chester, Va., paid physicians to make referrals for testing services and disguised the payments as consulting or medical director fees and also paid marketers commissions for the value or volume of referrals. Authorities also said that the lab submitted claims to Medicaid, Medicare and TriCare even though it knew about the kickbacks.

Deptford Center for Rehabilitation and Healthcare and Hammonton Center for Rehabilitation and Healthcare in New Jersey mismanaged millions of dollars in Medicaid funds while leaving residents in deplorable conditions, according to a report by the New Jersey Office of the State Comptroller. The report details a pattern of neglect and profiteering, including inflated rent payments and understaffing, while the owners diverted funds through deceptive financial arrangements.

Piedmont Health is leveraging artificial intelligence to enhance efficiency and the patient experience in the revenue cycle, says Allyson Keller, vice president of the Patient Connection Center. Projects include optimizing orders through interoperability, scaling automated voice assistants and improving speech recognition to better understand patient behavior. Keller highlights the potential of AI to automate clinical data extraction and ensure adherence to payer policies, which could reduce claim denials.

EHR alerts for malignancy, heart failure, opioid prescription or dementia can be set up to trigger initiation of advance care planning, according to a study in BMJ Open. Clinicians "can use the triggers identified in the EHR in an automated computer search to prioritise patients for [advance care planning]," researchers wrote.