What's New

• Artificial Intelligence in Healthcare
• Data Breach Notification
• Food as Medicine
• Fraud & Abuse
• Geriatrics
• Medicare Beneficiaries
• Provider Networks
• Staffing
• Texas Medicaid

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.