CMS Wants Ideas to CRUSH Sneaky Healthcare Scams in Medicare
Published Date: 2/27/2026
Proposed Rule
Summary
CMS wants your ideas to help stop healthcare fraud and protect taxpayer money. They’re thinking about new rules to catch sneaky scams in Medicare and Medicaid, and they need feedback by March 30, 2026. If you’re involved in healthcare or just care about fair spending, this could affect you!
Analyzed Economic Effects
12 provisions identified: 3 benefits, 6 costs, 3 mixed.
Citizenship/Residency for Owners
CMS is asking about a possible rule that would require U.S. citizenship or legal permanent residency for any individual with a 5 percent or greater ownership or control interest in a Medicare-enrolled provider or supplier. This proposal would directly affect Medicare-enrolled businesses that have non‑U.S. resident owners.
Expand Fingerprinting & Background Checks
CMS is considering expanding fingerprinting and criminal background check requirements beyond current rules that apply to 5 percent or greater owners in high‑risk organizations (42 CFR 424.518). Possible expansions could cover managing employees, owners with less than 5 percent interest, or other affiliated individuals.
MA/Part D Payment Suspension Authority
CMS notes it currently lacks affirmative regulatory authority to require Medicare Advantage organizations and Part D sponsors to suspend payments to providers and suppliers operating exclusively in Part C or Part D. CMS is asking whether it should create regulatory requirements allowing (or requiring) such suspensions similar to Traditional Medicare payment suspension authority (42 CFR 405.371).
Preclusion List and MA Enrollment Rule
CMS is soliciting feedback on strengthening the preclusion list because providers revoked from Traditional Medicare can sometimes shift billing to Medicare Advantage plans. CMS is asking whether MA billing should require enrollment in Traditional Medicare (Fee‑for‑Service) as a condition of billing MA plans, possibly for high‑risk provider types.
Lab Tests: MolDX Registration & Oversight
CMS highlights that Medicare Part B lab test spending was $8.4 billion in 2024 and that genetic tests were 5 percent of tests but accounted for 43 percent ($3.6 billion) of Part B lab spending. CMS is requesting feedback on new authorities and whether requiring laboratories to register in the MolDX program could reduce fraud, waste, and abuse.
DMEPOS Supplier Accreditation Requirement
CMS is seeking feedback on steps to address fraud by non‑participating DMEPOS suppliers billing Medicare Advantage plans, noting that Medicare payments for DMEPOS top more than $7 billion in Traditional Medicare alone. CMS asks whether MA organizations should require DMEPOS suppliers to be accredited and enrolled similar to Traditional Medicare.
Shorten Medicare Claim Filing Deadline
CMS is asking about reducing the Medicare Parts A and B claim filing deadline for high‑risk items and services from the current 1-calendar‑year deadline to a 90 to 180 calendar day deadline. CMS notes this is intended to reduce back‑billing that can obscure fraudulent claims.
Ban Unsolicited Outreach Beyond Phone
CMS is considering expanding the existing prohibition on unsolicited telephone contact by DMEPOS suppliers (section 1834(a)(17) of the Act and 42 CFR 424.57(c)(11)) to other forms of communication such as email, text message, and social media, and possibly expanding prohibited solicitation to other provider types. This would protect Medicare beneficiaries from solicitations seeking personal information.
Increase & Expand Surety Bonds
CMS is requesting feedback on strengthening the existing DMEPOS surety bond requirement, which currently requires a bond of at least $50,000, including options to increase the bond amount, require bonds for additional provider/supplier types, and strengthen surety company accountability. CMS also asks about similar bond changes for Medicaid and CHIP providers (for example, home health).
Stronger Medicaid/CHIP Integrity Tools
CMS is seeking feedback on expanding regulatory authority and tools to reduce fraud, waste, and abuse in Medicaid and CHIP, including whether states should require more frequent revalidation of high‑risk providers than the current 5‑year schedule. CMS is exploring technologies and reporting that states should provide to enhance program integrity.
Strengthen Exchange Agent & Broker Oversight
CMS is asking how to strengthen program integrity in the Federally Facilitated Exchange (FFE) and State‑Based Exchanges (SBEs), including improved oversight, vetting, and accountability for agents, brokers, web‑brokers, and direct enrollment entities, and better income verification to prevent fraudulent enrollments.
Use of AI for Coding & Billing Oversight
CMS is seeking input on using artificial intelligence (AI), including machine learning and commercial off‑the‑shelf products, to assist human coders with large volumes of records, improve coding accuracy, and increase hospital billing efficiency. CMS asks about features, display of AI recommendations, and compliance risks.
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