Welcome to another round of PYA Washington Updates. As summer winds down, it’s been a comparatively quiet week in the world of health policy.
Crushing Fraud, Waste & Abuse
CMS has launched a new webpage detailing its fraud-fighting successes and enlisting Medicare beneficiaries and their families to join the fight. Here are the successes reported for the first half of 2025:
- CMS imposed 223 Medicare payment suspensions on providers
- Over $1.3 billion in payments are on hold following payment suspension
- Through medical review activities, CMS fraud contractors identified $1.1 billion in overpayments across 1,539 Medicare providers
- Automated edits guarding against improper payments and potential fraud have denied payment for over 600,000 items or services, totaling over $106 million
- CMS revoked the ability of 3,152 providers and suppliers to bill the Medicare program due to inappropriate behavior
- Law enforcement accepted 186 CMS fraud referrals for potential legal action, encompassing $1.3 billion in billing
- 1-800-MEDICARE has received complaints related to fraud, waste, and abuse from over 130,000 beneficiaries (700+ calls per day)
Tariffs on Pharmaceuticals
On August 5, President Trump told CNBC’s Squawk Box that he intends to impose tariffs of up to 250% on pharmaceutical imports, the highest rate he’s mentioned to date. (Last month, he threatened to impose tariffs up to 200% “very soon.”) The President said the tariffs initially will be small, “[b]ut in one year, one [and] a half years maximum, it’s going to go to 150 percent, and then it’s going to go to 250 percent, because we want pharmaceuticals made in our country.” This announcement came the week after the administration sent letters to drug companies demanding they take more steps to reduce drug prices by September 29.
Rural Health Transformation Program
On CBS’ Face the Nation last Sunday, CMS Administrator Mehmet Oz was asked for specifics regarding the distribution of funds from OBBBA’s Rural Health Transformation Program. According to Dr. Oz, states will “get the applications in early September.” He offered no other details regarding how the $50 billion will be distributed to the states. Dr. Oz explained the program “is designed to help you with workforce development, right-sizing the system, and using technology to provide things like telehealth that can change the world.”
Increases in ACA Marketplace Rates
On Wednesday, Peterson-KFF Health System Tracker released its analysis of proposed 2026 rate increases for ACA Marketplace plans based on filings with state regulators. The analysis shows a median proposed premium increase of 18%, about 11 percentage points higher than the 2025 rate increases. In their filings, insurers explain the increases are due to rising healthcare costs and the expiration of premium tax credits. Without the enhanced tax credits, out-of-pocket premiums for ACA marketplace enrollees will increase by an average of more than 75%, with insurers expecting healthier enrollees to drop coverage. That, in turn, increases underlying premiums. And that means the federal government will be spending more on premium tax credits for those who still qualify. This report follows the release late last month of the annual PwC survey of health plan actuaries projecting an 8.5% increase next year for employer-sponsored plans.
PYA Webinars
2026 Medicare Physician Fee Schedule Proposed Rule – August 13
PYA’s second webinar addressing the 2026 MPFS proposed rule is scheduled for Wednesday, August 13. We will address telehealth changes, global payments reforms, new reimbursement methodology for skin substitutes, and updates to care management services and prevention and wellness programs. You can register for the webinar here. (And you can access the slides and a recording of the first MPFS webinar from July 30 here.)
2026 Medicare Hospital Inpatient Prospective Payment System Final Rule – August 27
Then, on August 27, PYA will present a webinar on the 2026 IPPS final rule, addressing updated payment rates, changes to the inpatient quality reporting program and hospital value-based purchasing programs, and details relating to the Transforming Episode Accountability Model, the mandatory alternative payment model set to launch on January 1, 2026. You can register for the August 27 webinar here.
Please do not hesitate to contact us if you have any questions regarding these latest developments, and please continue to check PYA’s website for updates.
