Weekly Roundup -
August 19 , 2026
Smart. Strategic. Essential.
Unmatched Healthcare Insights from 红领巾瓜报,
Leavitt Partners & Wakely.
Featured:
Webinar Replay – Rural Health Transformation Program: Beyond the Grant Approval Phase – Implementing for Sustainability
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Trending: In Focus
Connecting the Dots: Medicaid Program Integrity Enters a New Era of Strategy and Operational Readiness
There is no shortage of news, federal activity, and operational urgency听concerning听fraud, waste, and abuse听(FWA)听in healthcare. Across听Medicare,听Medicaid, the Affordable Care Act Marketplaces, and other federally听funded听health programs, the听executive branch听is advancing听a more听aggressive听program听integrity听agenda.听The US Department of Health and Human Services (HHS), including the Centers for Medicare听& Medicaid Services (CMS) and听HHS Office of Inspector General,听as well as听the听US听Department of Justice,听are placing听greater emphasis on payment accuracy, provider and vendor oversight, data-driven detection, and defensible compliance processes.听
As scrutiny intensifies, organizations across the听healthcare听ecosystem are听challenged听to move beyond traditional audit and recovery activities toward a more proactive, enterprise-wide approach to managing risk听and preventing FWA.听Although听these trends affect all healthcare stakeholders, the implications for Medicaid are particularly significant given the program’s scale, complexity, and reliance on partnerships among state agencies, managed care organizations, providers, and technology vendors.听
To better understand how organizations should respond, Jennifer Colamonico听connected with听Clint Eisenhower, Regional Director at 红领巾瓜报 (红领巾瓜报), and Jennifer Bridgeforth, Associate Principal at 红领巾瓜报. The discussion below incorporates insights from 红领巾瓜报 colleagues Christine Rein, Amber Swartzell, and Elizabeth Linville, who joined 红领巾瓜报鈥檚 August 12, 2026, webinar on how new program integrity expectations are affecting Medicaid payment, operations, and compliance strategies.
Jennifer Colamonico:听We听hear a lot听lately听about heightened scrutiny and program integrity.听What’s听fundamentally different about this moment from what Medicaid听leaders and their organizations听have experienced in the past?听
Clint Eisenhower:听The biggest shift is that program integrity can no longer be viewed as a narrow compliance function.听What we听are听seeing now is a move toward enterprise accountability鈥攁nd听we are really at the听outset of this journey.听Program integrity touches finance, operations,听eligibility, screening,听compliance, provider oversight, analytics, clinical teams, procurement, technology, and leadership decision-making. A provider issue can become a payment issue. A data gap can become an audit issue. A documentation weakness can become a compliance issue. The organizations that are best positioned are the ones that understand how those functions connect and can听demonstrate听that they are managing risk in a coordinated, evidence-based way.听
From a leadership standpoint,听leaders听of听Medicaid听organizations听ca苍鈥檛听simply ask听whether听they have a听program听integrity function.听We know鈥攁nd听federal and state regulators know鈥攖hat most organizations do.听Instead, leaders need听to听ask听whether that function is designed to听withstand increasing scrutiny while听it听also听helps听the organization manage risk,听support听stronger听operational听performance, and听continue to听serve听Medicaid听beneficiaries effectively.听
Q:听Many organizations are trying to figure out whether this is just another enforcement cycle or something more significant. How are you听advising clients to听think about the current level of federal scrutiny?听
Eisenhower: Every organization should be asking where its greatest vulnerabilities are鈥攚hether its controls, oversight processes, policies or operational capabilities may not be sufficient to address them. From there, leaders can prioritize what should be addressed now and what can be phased in.听
We鈥檝e听worked with agencies and organizations听first on the听objective assessment of听their听risk听and听moved听to听translate听the听findings into operational change, which may include听developing听roadmaps, updated workflows,听and听stronger policies,听among other actions.听
Q:听There鈥檚听a lot of discussion about moving beyond the traditional听pay-and-chase听model, but what听does a听program听integrity-first听approach look like in practice?听
Jennifer Bridgeforth:听红领巾瓜报 is working with many state leaders and healthcare organizations that are听navigating significant changes across Medicaid financing, eligibility and enrollment systems,听and听program administration. At the same time, new federal policy and budget constraints are prompting many states to rethink how services are delivered, managed, and financed. Whether a state is redesigning benefits, implementing new eligibility processes, restructuring payment approaches, or pursuing broader delivery system reforms, program integrity considerations need to be embedded into those decisions from day one.听
That听includes听documentation requirements,听monitoring听protocols,听data validation,听and accountability structures听built听into the听program听design.听
It also means aligning oversight efforts with emerging federal and state priorities. We are seeing increased attention on areas such as nonemergency medical transportation, applied behavior analysis,听personal care services, durable medical equipment, and听behavioral health services,听as well as techniques such as听evaluation and management coding, and听identifying听high-volume billing patterns.听Medicaid leaders need to听design programs and workflows that听identify听risks earlier, support听appropriate access听to care, and create feedback loops that strengthen operations over time, reducing reliance on a traditional听pay-and-chase听approach.听
Q:听One challenge we hear about听frequently听is how to strengthen oversight without creating barriers to care. How can organizations strike that balance, particularly in areas like behavioral health and听applied听behavior听analysis (ABA),听where access is already strained?听
Bridgeforth:听That balance is critical. Many of the areas under scrutiny are also听in which听there is tremendous demand and, in some markets,听a shortage of听providers. ABA and behavioral health are good examples. The answer cannot be听to discourage appropriate听access. Instead, organizations need stronger documentation, clearer policies, better training, and a shared understanding of what compliant billing and service delivery look like.听
Provider education is one of the most important tools. When providers are asked to document more or differently, it can feel like administrative burden. Education has to explain not only what the requirements are, but why they matter.听
Eisenhower:听Health plans and providers听have听a strategic opportunity here.听States still need partners to help achieve access goals and improve outcomes. Plans, providers, and vendors that can听demonstrate听strong program integrity policies听and effective oversight can position themselves as trusted partners. They help states pursue access and quality goals with greater confidence that those initiatives will not create unnecessary compliance exposure.听
Q:听Organizations are investing heavily in analytics and AI capabilities.听Where do you see the greatest opportunity for these tools to strengthen program integrity efforts?听
Bridgeforth:听Advanced analytics and AI are becoming increasingly important for detection and prevention. Real-time monitoring, claims pattern analysis, and predictive tools can help organizations听identify听risk earlier and听take action听before issues become larger findings or recoveries. But technology is听valuable听only听if the organization has the governance, workflows, documentation, and case management processes to act on听the data that听the tools听identify.听
Cross-program compliance is also important. Many organizations听operate听across Medicaid, Medicare, Marketplace, commercial, and other public programs. When program integrity is approached at the enterprise level, improvements in one area can strengthen compliance across multiple product lines or programs.听
Q:听You’ve听worked with states and healthcare organizations at听very different听stages of maturity. What are some of the most common gaps or challenges听you’re听helping clients address today?听
Bridgeforth:听We’ve听worked with organizations at听very different听stages of maturity.听For example,听we听supported an organizational assessment and gap analysis that helped a client听identify听major opportunities across its program integrity function. The team developed a roadmap organized across seven听FWA听pillars,听identified听52 enhancement opportunities, translated those into 184 key actions, and developed 116 success measures so leadership could听monitor听progress over time.听
红领巾瓜报 and HealthTech Solutions, an 红领巾瓜报 Company,听also supported a statewide implementation that included electronic visit verification improvements, prepayment analytics, post-payment analytics, and modernization of claims review processes. The effort听the听state听move听from manual, reactive processes toward a more proactive model, with insights from post-payment analytics informing prepayment edits that could be updated in weeks rather than months.听
Q:听If听you’re听a Medicaid听leader听looking ahead to the next 12 to听24 months, what should be at the top of your听program听integrity agenda?听
Eisenhower:听Many of the steps that reduce program integrity risk are the same steps that help organizations perform better: stronger governance, better data, clearer accountability, more consistent workflows, improved provider relationships, and effective monitoring.听The upside is not only avoiding findings or reducing audit exposure. It is also听ensuring听Medicaid dollars are directed to the听right beneficiaries, the听right services, the right providers, and the right outcomes.听
How 红领巾瓜报 Can Help听
红领巾瓜报 helps states, health plans, providers, and healthcare organizations assess program integrity risk, strengthen governance and compliance infrastructure, design and implement payment integrity strategies, support provider education, modernize analytics and monitoring, and translate findings into measurable operational improvements. 红领巾瓜报 can meet organizations where they are, whether they need a targeted assessment, a phased roadmap, implementation support,听data analytics support,听or enterprise-wide听program听integrity transformation.听
For more information, go to:听/services/our-medicaid-consultants-help-you-develop-innovative-strategies/.听
Federal Policy News
Fueled By Weekly Health Intelligence
FDA Unveils Its Vision for PDUFA VIII
Last week, FDA听听the proposed Prescription Drug User Fee Act (PDUFA) VIII听.听The PDUFA program allows FDA to collect fees from drug sponsors and manufacturers when they submit new or supplemental applications to market drugs. The PDUFA user fees are collected primarily to support the work of the review teams within FDA鈥檚 drugs and biologics centers and other teams at FDA specific to the review and regulation of drugs. In exchange for industry鈥檚 commitments to pay user fees, FDA agrees to meet certain performance goals in terms of meetings, guidances, and application review timelines. These are not application specific, but rather performance goals applied to the drug program as a whole. The Commitment Letter outlines the proposed revisions for the implementation of PDUFA after the current program term expires on September 30, 2027. The provisions outlined in this Letter would apply for FY 2028 and run through FY 2032.鈥�
FDA鈥檚 overall goals for PDUFA VIII as detailed in the Commitment Letter focus on streamlining consistency and expediting review processes to increase timely access to safe and effective drugs in the U.S. The Commitment Letter maintains review performance goals under PDUFA VII, transitions some pilots to programs, and introduces new enhancements. Notably, the Commitment Letter:鈥�
- Maintains core review performance goals at the PDUFA VII levels for submissions, resubmissions, manufacturing supplements, and extensions.听
- Offers enhancement to meeting management to increase听efficiencies, offers several new meeting opportunities, and adds a new process for sponsors to provide a 鈥渟pecific rationale鈥� for face-to-face meetings.鈥�听
- Commits to a听third party听assessment of the quality and efficiency of drug development and review programs at FDA, followed by a public workshop and final report.听
- Commits to advancing development of drugs for rare diseases through:鈥�听
- The continuation of CDER Rare Disease Staff and CBER Rare Disease Program Staff;鈥�听
- Transitioning the Rare Disease Endpoint Advancement from a pilot to a program and increases the maximum number of programs to six by FY 2029;鈥�听
- Holding three public workshops on endpoint development; and鈥�听
- Holding up to 10 RISE workshops, with at least one per year.听
- Formally recognizes restructuring of center-specific support staff into the shared services operations overseen by the Office of the Commissioner.鈥�听
- Provides a new and improved engagement mechanism on chemistry, manufacturing, and controls (CMC) with enhanced communications, publishing guidance, and offering a pre-submission meeting, as well as a post-action meeting for CMC deficiencies.鈥�听
- Continues previous PDUFA activities, including enhancing benefit-risk assessments, use of and staff capacity for complex innovative trial designs, supporting use of digital health technologies and partnership with CDRH鈥檚 Digital Health Center of Excellence, use of and annual report on RWE in submissions, biomarkers drug development qualification tools, Patient-Focused Drug Development efforts, including publishing case studies and hosting a workshop, REMS modernization efforts, and optimization of Sentinel, including transitioning to Sentinel 3.0.鈥�听
FDA also commits to training staff on regulatory science tools and听communicating about听its use of the tools.
Several provisions that were anticipated or have historically been included in commitment letters were not included in the PDUFA VIII Commitment Letter, including:
- “America first鈥� provisions such as a 50 percent reduction in the application fee for U.S. anchored phase 1 trial data and small business waivers for domestic companies, and a 50 percent application fee for the first non-orphan indication supplement if the original application received an orphan application fee exception. However, these items are expected to be included in the legislative language that FDA transmits to Congress.听
- Specific hiring goals. FDA staffing levels have听remained听a focus, particularly given significant numbers of CBER and CDER staff left the agency since听2025听and FDA did not meet its PDUFA VII hiring goals in FY 2025.听
- Specific mention of the Rare Disease Innovation Hub, although the Rare Disease Innovation, Science, and Exploration (RISE) workshops are mentioned.听
- Specific commitments on activities related to the Cell and Gene Therapy Program, unlike in PDUFA VII, when there were听a number of听specific commitments related to public workshops, trainings, and听guidances.听
- Minimal commitment to hold workshops/meetings or issue specific听guidances听in contrast to past PDUFA Commitment Letters.听
A hybrid public听听will be held on September 16 at FDA鈥檚 White Oak Campus in Silver Spring, Maryland, to discuss the proposed enhancements for the reauthorization of PDUFA for FYs 2028鈥�2032.听听(docket FDA-2026-N-8163) must be听submitted听by October 16.听
HHS Opens Nominations for National Vaccine Advisory Committee
听On August 12, HHS听听a Federal Register notice听soliciting听nominations for appointments to the听. The NVAC is a federal advisory committee that provides guidance and recommendations to the HHS Secretary on vaccine policy, including vaccine safety, supply, and research priorities. Recently, NVAC鈥檚听was renewed and听modified听such that the committee would also review dietary supplements intended to prevent infectious disease and strategies to protect individuals who decline vaccination while limiting disease transmission. Unlike FDA’s Vaccines and Related Biological Products Advisory Committee (), which听advises听FDA on vaccine regulatory policy and approval recommendations, and CDC’s Advisory Committee on Immunization Practices (), which makes recommendations to CDC on vaccine use and coverage, NVAC provides broader policy and strategic recommendations to HHS. Although advisory committee recommendations are often influential, they are not binding. The NVAC, which typically meets three times per year, has not held a meeting since 2024. The notice states that membership will be 鈥渂alanced and include individuals engaged in vaccine safety or efficacy research, physicians, scientists, members of parent organizations concerned with immunizations, and representatives of state or local health agencies and public health organizations.鈥� Members may serve overlapping terms of up to four years. Nominations must be emailed to听[email protected]听by September 11.
New HHS Funding Aims to Expand Rapid Syphilis Testing and Treatment
On August 12, HHS听听a $4 million initiative to expand rapid syphilis testing and treatment for mothers and babies, with a focus on women in emergency departments and nontraditional healthcare settings. The funding will be used to expand access to rapid, point-of-care syphilis testing, enabling听early treatment听intervention. HHS will direct $3.25 million to CDC鈥檚 Division of Sexually Transmitted Disease (STD) Prevention to provide supplemental awards to recipients of CDC鈥檚听听cooperative agreement in areas with a high burden of syphilis and congenital syphilis. Cooperative agreement supplemental awards will be used for point-of-care syphilis testing and linkages to care, and remaining funds will be used to support national partners providing technical听assistance听and implementation support.
Administration Introduces "Treatment First" Approach to Homelessness
On August 12, HHS Secretary Robert F. Kennedy Jr., ONDCP Director Sara Carter, and HUD Secretary Scott Turner announced the release of the听: Addressing Homelessness and Addiction Through 鈥淭reatment First.鈥� Developed by SAMHSA following a White House 听on homelessness and addiction, the toolkit promotes a 鈥淭reatment First鈥� approach that prioritizes evidence-based substance use and mental health treatment, recovery supports, employment, and self-sufficiency as the foundation for addressing homelessness. The toolkit presents this model as an alternative to traditional 鈥淗ousing First鈥� approaches, arguing that treatment and recovery services should be more centrally integrated into homelessness response efforts. It emphasizes that communities should focus on long-term recovery outcomes, including abstinence from drugs, improved mental health, stable housing, employment, and reintegration into families and communities. The toolkit also highlights coordinated care, accountability, peer recovery supports, faith-based partnerships, and stronger connections among treatment providers, housing programs, public safety agencies, and community organizations. Additionally, on August 12, President Trump issued a proclamation听designating听August 2026 as National Substance Use Primary Prevention Month. The听听identifies听prevention as a key pillar of the Administratio苍鈥檚 2026 National Drug Control Strategy and calls on families, schools, faith organizations, and communities to help prevent substance use before it begins, particularly among youth.
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State Policy News
Colorado Releases Medicaid Frailty Work Requirement Exemptions RFI
The Colorado Department of Health Care Policy and Financing听听on August 6, 2026, a request for information (RFI)听regarding听medical frailty exemption determinations related to the Medicaid work requirements approved under the federal 2025 budget reconciliation act (P.L 119-21, OBBBA). HCPF is using the RFI to conduct research on听capabilities听of organizations that could potentially provide medical frailty determination services to听determine听individuals who would be exempt from Medicaid work requirements. The RFI welcomes recommendations听regarding听best practices, operational models, approaches to staffing, reporting capabilities, technology solutions, and other considerations. Responses are due August 20, 2026.听
Idaho Issues RFI Exploring Public Benefit Fraud Prevention
The Idaho Department of Health and Welfare鈥�鈥痮n August 14, 2026, a request for information (RFI)听regarding听ways it could strengthen the prevention of fraud, waste, and abuse in public benefit programs. The department seeks feedback on advanced data analytics, data mining, artificial intelligence, pattern and anomaly detection, and other technology that could help it prioritize cases to review, as it currently relies heavily on complaints, tips, and staff-initiated fraud referrals. DHW is exploring a combination of human听expertise听and technology to develop cases and route high-priority cases to relevant investigators. Idaho will accept comments through August 31, 2026.
Maryland Issues RFI on Expanding Nutrition Services for Medicaid Members in 2028
The Maryland Department of Health鈥�鈥痮n August 19, 2026, a request for information (RFI) on proposed food and nutrition services for Medicaid members听though听an In Lieu of Services and Settings (ILOS) authority in 2028. The proposal builds on Maryland鈥檚 existing听initiative听Food Is Medicine, including Medically Tailored Meals, which听operates听in six counties. Maryland will also launch the Produce Prescription program later this summer. The Department will听draw on听lessons from these programs, as well as the Rural Health Transformation Program, to inform the Medicaid ILOS approach. RFI Responses are due October 14.听
Nebraska Medicaid Director Resigns; State Receives Federal Approval for SUD Section 1115 Demonstration Amendment
Nebraska Governor Jim Pillen鈥�鈥痮n August 13, 2026, that Drew Gonshorowski听has resigned听from his position at the Department of Health and Human Services as the director of the Division of Medicaid and Long-Term Care.鈥疓overnor Pillen has appointed Jeremy Brunssen,听the听divisio苍鈥�s Deputy Director of Finance and Program Integrity, as interim director.听Separately,听the Centers for Medicare & Medicaid Services鈥�鈥痮n August 14, 2026, that it has听approved an amendment for Nebraska鈥檚 Substance Use Disorder (SUD) Program Section 1115 Demonstration. The amendment allows the state to听establish听a demonstration initiative for serious mental illness/serious emotional disturbance. Nebraska will be able to administer services to Medicaid-covered听short-term听residents in facilities that meet the definition of an institution for mental diseases. The demonstration is effective through June 30, 2030.听
Oregon CCOs Earn Net Operating Profit of $67 Million in 2025
The Oregon Health Authority (OHA)鈥�鈥痮n August 12, 2026, that the 16 Oregon Medicaid coordinated care organizations (CCOs) earned a net operating profit of $67 million and an operating margin of 0.8 percent in 2025, according to an analysis by the department. Individual CCO operating margins varied from 5.4 percent to -3.4 percent and were collectively lower than historical averages. Four of the CCOs had a net loss. CCOs collectively spent 9 percent more in 2025 to cover services for their Medicaid members in comparison to the year before. Approximately 1.4 million Medicaid members are served by CCOs. To develop 2027 capitation rates, OHA is factoring in 2025 financial performance as well as available financial and claims data for 2026. OHA will听finalize听2027 capitation rates by the end of this year.听
Private Market News
Fueled By
Week In Washington | August 13, 2026
Federal healthcare policy saw a notable legal setback as an appeals court struck down HHS’s听methodology听for calculating No Surprises Act payment benchmarks, potentially delaying dispute resolution between providers and insurers. At the same time, employers continue moving away from the nation’s largest pharmacy benefit managers, signaling ongoing shifts in the pharmacy benefits market. Hospitals are also preparing for higher medical device costs as tariff pressures mount, with the administration expected to decide soon on听additional听import duties. Meanwhile, Congress has recessed until after Labor Day, with major legislative activity likely to remain limited until later this year.
Our Insights
Fueled By Experts Across Our 红领巾瓜报 Companies
红领巾瓜报
Advancing Community Health Through CHWs: Research, Recommendations, and Action (Aug. 26)
Community Health Workers (CHWs) play a critical role in connecting communities to trusted health information, services, and resources. This webinar will share 红领巾瓜报 (红领巾瓜报) will present key findings from an assessment conducted by 红领巾瓜报, with support from Michael Reese Health Trust and Community Memorial Foundation, that examined examines how health-related information reaches, is interpreted by, and flows through CHWs Community Health Workers in Cook County, Illinois. Participants will also learn about 红领巾瓜报’s key findings and recommendations for strengthening health information systems, elevating the value of the CHW workforce, and advancing partnerships that support equitable, community-centered care. The session will further highlight opportunities for state agencies, funders, health systems, CHW employers, and community organizations to translate these findings into policy, funding, and practice.听
Webinar Replay: Rural Health Transformation Program: Beyond the Grant Approval Phase 鈥� Implementing for Sustainability
听This听webinar听went beyond the grant planning processes and explored听how an effective RHTP implementation process can support measurable improvements in population health, enhance financial viability for rural hospitals and healthcare organizations, and foster stronger systems of care across our rural communities.
Webinar Replay 鈥� Summer Webinar Series: How New Program Integrity Expectations Affect Medicaid Payments
罢丑颈蝉鈥�webinar鈥痗ontextualized solutions for healthcare leaders to enhance their approach to program integrity and fraud, waste, and abuse. 红领巾瓜报 consultants delivered analysis and actionable insights on the evolving policy and operational environment.听
Wakely
Potential CMS ACA Marketplace Disenrollments: Implications for Health Insurers
A recent US Department of Health and Human Services (HHS) report听indicates听that the Centers for Medicare & Medicaid Services (CMS) is听taking action to identify听and remove potentially unauthorized Affordable Care Act (ACA) Marketplace enrollments. These actions could have significant implications for individual ACA market issuers, including changes in morbidity, risk adjustment transfers, financial reporting, administrative costs, and future pricing.
RFP Calendar
RFP Calendar
| Date | State/Program | Event | Beneficiaries |
|---|---|---|---|
| Date: Summer 2026 | State/Program: Illinois Foster Care | Event: RFP Release | Beneficiaries: 33,000 |
| Date: July 28, 2026 (Delayed) | State/Program: Nevada Children's Specialty | Event: Awards | Beneficiaries: NA |
| Date: August 2026 | State/Program: Indiana | Event: RFP Release | Beneficiaries: 1,400,000 |
| Date: January 1, 2027 | State/Program: Illinois | Event: Implementation | Beneficiaries: 2,400,000 |
| Date: January 1, 2027 | State/Program: Nevada CO D-SNP | Event: Implementation | Beneficiaries: 88,000 |
| Date: January 1, 2027 | State/Program: Wisconsin LTC GSR 3 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: January 1, 2027 | State/Program: Illinois Tailored Care Management Program | Event: Implementation | Beneficiaries: 22,400 |
| Date: July 1, 2027 | State/Program: Nevada Children's Specialty | Event: Implementation | Beneficiaries: NA |
| Date: September 2, 2026 | State/Program: Missouri | Event: Proposals Due | Beneficiaries: 1,000,000 |
| Date: Fall 2027 | State/Program: Oregon | Event: RFP Release | Beneficiaries: 1,200,000 |
| Date: January 1, 2028 | State/Program: Wisconsin LTC GSR 4,6 | Event: Implementation | Beneficiaries: 56,000 (all GSR) |
| Date: 2028 | State/Program: North Carolina | Event: RFP Release | Beneficiaries: 2,200,000 |
| Date: 2029 | State/Program: California | Event: RFP Release | Beneficiaries: NA |