The Regulator

67 percent: that is the share of Medicare Advantage prior-authorization denials that get overturned when patients or doctors actually appeal them, the first insurer-by-insurer numbers a federal rule has ever forced into public view. Under the Centers for Medicare and Medicaid Services’ 2024 Interoperability and Prior Authorization Final Rule, Medicare Advantage organizations, state Medicaid and Children’s Health Insurance Program managed care plans, and Affordable Care Act marketplace insurers had to post prior-authorization approval and denial metrics for calendar year 2025 on their own websites for the first time, by March 31, 2026. KFF’s August 13, 2026 analysis of that newly public data, covering 14 major insurers and roughly 71 million enrollees, found standard-request denial rates averaging 12 percent in Medicare Advantage, 14 percent in Medicaid managed care and 18 percent in Affordable Care Act marketplace plans, ranging as low as 5 percent (Elevance, Medicare Advantage) to as high as 25 percent (Centene, Affordable Care Act marketplace). Appeals succeed more often than not, 67 percent of appealed Medicare Advantage denials, 47 percent of Medicaid managed care denials and 43 percent of marketplace denials got overturned, though the reporting requirement does not track how many denied patients ever file an appeal in the first place. Confidence: High. This run reviewed KFF’s analysis and the underlying CMS rule directly. Sources: Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain, KFF, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), Centers for Medicare and Medicaid Services.

85 percent: that is the share of No Surprises Act billing arbitrations where doctors and hospitals won more than insurers’ own benchmark rate, a gap the full Fifth Circuit says proves regulators let insurers rig that benchmark from the start. The U.S. Court of Appeals for the Fifth Circuit, sitting en banc, ruled August 11, 2026 in Texas Medical Association v. HHS that the qualifying payment amount, the benchmark insurers use to make initial payment offers and that arbitrators weigh heavily in No Surprises Act billing disputes, was unlawfully calculated under a 2021 interim final rule. The court held regulators wrongly let insurers include “ghost rates,” contracted rates for services providers never actually deliver, while excluding real bonus and incentive payments, both of which artificially suppressed the benchmark insurers pay against millions of out-of-network claims a year. The ruling vacates those portions of the rule and orders federal agencies to write a new methodology, though existing calculations stay in use in the interim under the agencies’ enforcement discretion, discretion HHS’s own guidance had said would not extend past August 1, 2026. Confidence: High on the ruling’s holdings, drawn directly from the court’s opinion; Medium on the practical interim-continuity detail, which reflects trade-press interpretation. Sources: Texas Medical Association v. U.S. Department of Health and Human Services, Opinion, U.S. Court of Appeals for the Fifth Circuit, Providers win Texas No Surprises Act case over QPA, STAT.

60 billion dollars: that is the federal Medicaid money flowing to hospitals in at least 37 states and Washington, D.C. that a new analysis says would not survive a Trump administration rule capping what states can direct Medicaid health plans to pay. CMS proposed rule CMS-2449-P, published in the Federal Register May 22, 2026, would implement Section 71116 of the 2025 reconciliation law by capping new “state directed payments,” arrangements where states require Medicaid managed-care plans to pay providers above the plans’ normal rates, at 100 percent of Medicare rates in Medicaid expansion states and 110 percent in non-expansion states, replacing a standard that let states direct payments up to average commercial rates. Existing arrangements above that cap are grandfathered only until 2028, then phased down. KFF’s August 14, 2026 analysis found California stands to lose the most at $7.4 billion, followed by Illinois ($4.0 billion), Kentucky ($3.9 billion), Texas ($3.5 billion), North Carolina ($3.4 billion), Louisiana ($3.3 billion), Arizona ($3.0 billion) and Michigan ($2.6 billion), with those eight states accounting for roughly half the national total; CMS itself has estimated the reconciliation law’s state-directed-payment changes would cut federal Medicaid spending by $510 billion between 2026 and 2035. Confidence: High on the rule’s mechanics, dated to the Federal Register filing; Medium on the state-by-state dollar breakdown, which reflects KFF’s own modeling rather than a CMS-published state table. Sources: Medicaid Program; Medicaid Managed Care State Directed Payments and Medicaid Fee-for-Service Targeted Medicaid Practitioner Payments, Federal Register, Analysis: At Least 37 States Have Medicaid State Directed Payments for Hospital Services That Could Be Reduced by the 2025 Reconciliation Law Limits, KFF.

8 million dollars: that is how much a former Brooklyn bank branch manager admitted laundering for a Russia-based crime ring that prosecutors say ran a multi-billion-dollar Medicare fraud scheme through dozens of shell medical equipment companies. Renat Abramov, 37, a former relationship manager at a bank branch in Brooklyn’s Sheepshead Bay neighborhood, was sentenced August 12, 2026 to 18 months in prison after pleading guilty in February 2026 to conspiracy to commit money laundering. Prosecutors said Abramov acted as a “concierge banker” for a transnational criminal organization based in Russia, opening accounts for nominee owners, many not lawfully present in the United States, who fronted dozens of durable medical equipment companies used to submit fraudulent claims to Medicare and private insurers, then moved more than $8 million of those fraud proceeds through accounts he controlled. Confidence: Medium. This run could not independently retrieve the Justice Department’s own release, which returned an access error, but HHS OIG’s enforcement listing and multiple outlets citing the plea and sentencing directly corroborate the sentence, dollar figure and scheme description. Sources: Former Brooklyn Bank Manager Sentenced to Prison for Laundering Proceeds of Medicare Fraud for Transnational Criminal Organization, HHS Office of Inspector General, Former Brooklyn Bank Manager Sentenced to Prison for Laundering Proceeds of Medicare Fraud for Transnational Criminal Organization, U.S. Department of Justice release via GlobalSecurity.org.

558,383 dollars: that is how much six Ohio Medicaid providers are accused of stealing by billing for behavioral health, home care and personal-care services they never delivered, in the state’s fourth batch of provider indictments since early summer. Ohio Attorney General Andy Wilson announced August 13, 2026 that a Franklin County grand jury indicted six providers statewide: Rasheedah Biles of Pickerington, who ran the behavioral health company Reset Tomorrow and is accused of inflating and fabricating children’s behavioral-health claims worth $404,810 over two years; Sasi Kaza of Clinton, owner of Moonlight Home Health Care, accused of billing for maximum authorized hours regardless of whether services were delivered, including for clients who were hospitalized or had died, totaling $53,405; and four home-care and personal-care workers, Dorika Carter, Carol Dawes-Willis, Yvette Johnson-Woodall and Binetou Ndao, accused of billing for shifts they worked elsewhere, while hospitalized, or never showed up for, together accounting for the remaining $100,168. All six face Medicaid fraud and theft charges in Franklin County Common Pleas Court. Confidence: High. The Ohio Attorney General’s own press release states the defendants, dollar figures and allegations directly. Sources: Six Medicaid Providers Indicted on Fraud Charges, Ohio Attorney General.