The Regulator

The federal government named the first cohort of a new Medicare accountable care model this week, and once an existing accountable care organization (ACO) signs onto the model’s highest-risk track, it cannot back out for the rest of the model’s 10-year run. The Center for Medicare and Medicaid Innovation posted its “Implementation Period Participant List” to the Long-Term Enhanced ACO Design (LEAD) Model page September 25, 2026, naming 79 ACOs taking part in an optional preparation period that runs through December 31, 2026 ahead of the model’s January 1, 2027 start. Sixty-five of the 79 chose the “Global” full-risk track and 14 chose “Professional,” a partial-risk option; CMS says it is working with “well over 100” ACOs preparing for the model’s first performance year and that participating ACOs “have until mid-December to finalize participation.” LEAD succeeds the ACO REACH model and runs for a full decade, and under CMS’s own program rules an ACO renewing into the model cannot switch from Global back to Professional risk once it signs its participation agreement, locking in a full-risk bet on Medicare spending benchmarks for years. Confidence: High. This run reviewed CMS’s own participant list directly; the renewal-lock detail is confirmed through legal analysis of CMS’s LEAD Model FAQ. Sources: Implementation Period Participant List, CMS Innovation Center, LEAD Model, CMS Innovation Center, CMS Bets on the Long Game With 10-Year LEAD ACO Model, Benesch Law.

Elevance Health’s opening brief in its fight over 2026 Medicare Advantage Star Ratings is due tomorrow, and both the insurer and the government have asked the court to rule by December 14, in time to shape 2027 quality bonus payments. A joint motion filed September 18, 2026 in the U.S. District Court for the Southern District of Georgia set a briefing schedule in Elevance Health, Inc. et al. v. Department of Health and Human Services: Elevance’s summary judgment motion is due September 28, the Centers for Medicare and Medicaid Services’ (CMS) cross-motion and administrative record are due October 19, and final replies are due November 18. Elevance and its Wellpoint subsidiaries argue CMS should recalculate their Star Ratings the same way a court forced CMS to recalculate Clover Health’s, a fix Elevance has said would be worth $115 million in quality bonus payments. Two related cases in Washington, D.C., SCAN Health Plan’s $125 million claim and Alignment Healthcare’s $50 million claim, have similar briefing nearly complete before a different judge, meaning three courts could rule on the same Star Ratings methodology dispute within months of each other. Confidence: High. This run reviewed the court filing directly. Sources: Joint Motion to Enter Briefing Schedule, U.S. District Court for the Southern District of Georgia via CourtListener, Elevance Health, Inc. et al. v. Department of Health and Human Services et al., Georgetown Health Care Litigation Tracker.

A federal watchdog found that the agency overseeing Medicaid managed care cannot reliably tell whether the spending reports insurers file are even accurate, undercutting the main check on whether Medicaid dollars go to patient care instead of profit. The HHS Office of Inspector General (OIG) reported September 21, 2026 that CMS’s process for checking state-submitted Medicaid managed care medical loss ratio (MLR) data has limitations: CMS conducts only limited accuracy checks on the four data elements states must report, does not consistently follow up with states that submit questionable figures, and does not share what it finds with the CMS staff who set Medicaid managed care payment rates. The federal MLR standard requires managed care plans to spend at least 85 percent of Medicaid premium dollars on patient care and quality improvement rather than administration or profit, a threshold states and CMS use to help set future capitation rates. OIG made three recommendations, all agency staff coordination and follow-up procedures, and CMS agreed with all three. Confidence: High. This run reviewed the OIG report directly. Sources: Medicaid Managed Care: CMS’s Accuracy Check Process for State-Submitted Medical Loss Ratio Data Has Limitations, HHS Office of Inspector General.

A Massachusetts nursing home operator agreed to pay $1 million this week after prosecutors said an executive altered patient records, without ever speaking to the patients, to justify billing Medicare and Medicaid for the most intensive level of rehab therapy. The Department of Justice and Massachusetts Attorney General Andrea Campbell announced September 23, 2026 that RegalCare Management Group LLC, RegalCare Management 2.0, owner Eliyahu Mirlis and executive Hector Caraballo agreed to pay $1 million to resolve False Claims Act allegations covering 2018 through 2023. Prosecutors said Caraballo, who was not licensed to make such determinations, modified skilled nursing facility records to support billing at the “Ultra High” Resource Utilization Group level, the highest-reimbursing therapy-intensity tier, without assessing or speaking to the patients or consulting their clinicians. The case follows a related March 2026 settlement with RegalCare’s therapy contractor, Stern Therapy, over the same billing pattern. Confidence: High. This run reviewed the Department of Justice’s press release directly. Sources: Skilled Nursing Company and Executive Agree to Pay $1 Million to Resolve Overbilling Allegations, U.S. Department of Justice, AG Campbell Announces $1 Million Settlement With Nursing Facility Operator RegalCare, Massachusetts Attorney General.

A Florida physician was sentenced this week to probation rather than prison for signing paperwork, for patients he never spoke to, that let a telemedicine operation bill Medicare more than $3.1 million. A federal judge in the District of Massachusetts sentenced Simon Grinshteyn, 52, on September 22, 2026 to four years of probation, six months of home confinement, 400 hours of community service and $3,160,809.43 in restitution. Grinshteyn pleaded guilty to making false statements after prosecutors said that between February and June 2020 he signed pre-populated medical records and orders for a telemedicine company that made it appear he had examined Medicare beneficiaries and would provide their ongoing care, when he had no direct contact with them; laboratories and durable medical equipment suppliers then used his signatures to bill Medicare for unnecessary genetic testing and equipment. Confidence: Medium-High. The Department of Justice’s own press release was confirmed as the primary source but could not be directly retrieved this run; the sentence, restitution figure and case details were independently corroborated by multiple outlets that quoted the release directly. Sources: Florida Doctor Sentenced for Making False Statements in Connection with Multi-Million-Dollar Health Care Fraud Scheme, U.S. Department of Justice.

Arkansas hospitals, clinics and paramedic programs are splitting $54.6 million in federal money announced this week, part of a $50 billion program built to keep rural health systems afloat as reimbursement pressure squeezes them. CMS announced the award September 24, 2026 under the Rural Health Transformation Program: $27.4 million funds 30 chronic-disease and prevention projects, including mobile preventive screenings and nutrition and physical-activity programs, and $27.2 million funds 24 workforce projects, including rural residency programs, clinical training, nursing and behavioral health workforce development, expanded maternal health staffing, and new emergency medical technician and paramedic training. The award is Arkansas’s share of the five-year, $50 billion, 50-state program created under last year’s federal reconciliation law. Confidence: High. This run reviewed CMS’s own press release directly. Sources: Trump Administration Announces $54.6 Million to Fight Chronic Disease, Expand Maternal Healthcare Services, and Build Arkansas’ Rural Health Workforce, Centers for Medicare and Medicaid Services.