The Regulator

180 million: that is how many Americans get health coverage through employers that pay claims themselves, and five of the biggest now want electronic prior authorization extended to those plans. The Centers for Medicare & Medicaid Services (CMS) and the Department of Labor announced October 21 that Amazon, Axon Enterprise, Google, Meta and Oracle signed a statement of support. It asks the outside administrators that run self-funded plans to meet the commitments health insurers made in the 2025 Prior Authorization Pledge, which cover standardizing electronic requests, cutting the services that need approval and speeding responses. Who it hits: third-party administrators and the employers that hire them. So what: the statement sets no deadline and binds no one; the binding date is separate, because the CMS Interoperability and Prior Authorization Final Rule requires certain payers to implement electronic prior authorization starting January 1, 2027. CMS cites Census data that more than 53% of Americans are covered by self-funded employers. Confidence: High on the announcement and signatories; Low on any near-term change in how fast approvals come. Sources: CMS press release, CMS employer statement of support.

Illinois: a laboratory executive is indicted for billing a federal program $66.2 million for COVID-19 tests prosecutors say were never run. A federal grand jury in the Northern District of Illinois charged Rajesh “Raj” Patel, 52, co-owner and chief operating officer of a clinical laboratory in Hillside, with five counts of wire fraud. The Justice Department says that from May 2021 to April 2022 he created fake negative results for at least 380,000 tests. The lab billed the Health Resources and Services Administration (HRSA) Uninsured Program, which pays for COVID-19 tests for people without insurance, and was paid about $44.1 million. Prosecutors say Patel personally received about $28 million. Each count carries up to 20 years in prison. An indictment is an allegation, and Patel is presumed innocent until proven guilty. Confidence: High on the charges as alleged. Sources: Justice Department press release, HHS-OIG enforcement action.

Maryland: a federal jury convicted a laboratory owner of billing Medicare $18.7 million for respiratory tests nursing home residents did not need. Patrick Britton-Harr, 42, of Annapolis, owned an Arizona laboratory operated through his company Provista Health. The Justice Department says that in six months he billed Medicare more than $18.7 million for respiratory pathogen panel tests, and Medicare paid more than $7.2 million. Jurors convicted him on five counts of health care fraud and one count of transactional money laundering. The OIG summary says the tests were not needed, not ordered by physicians and, in many cases, never performed. Each count carries up to 10 years; sentencing has not been scheduled. Confidence: High on the verdict and amounts. Sources: Justice Department press release, HHS-OIG enforcement action.

Mississippi: about $32 million in rural health awards, including three new psychiatric emergency units next to hospital emergency rooms. CMS announced October 21 that Mississippi will receive 60 awards from the Rural Health Transformation Program, the $50 billion fund created by the Working Families Tax Cuts Act. The money will go to recruiting and retaining primary care physicians, expanding clinical training and career pathways, and opening the three units. CMS did not name the recipients or locations of the units and does not state the state’s total fiscal 2026 allocation; members of Congress cite $32.6 million. So what: hospitals and training programs in the state can now plan around funded awards, but the release gives no per-award amounts. Confidence: High on the announcement; Low on who receives what. Sources: CMS press release.

CMS plans to match its records against Veterans Health Administration enrollment to find duplicate payments. A Privacy Act notice published in the Federal Register October 21 describes a computer matching program with the Veterans Health Administration to identify dually enrolled beneficiaries, recover duplicate payments and flag potential fraud. I could not retrieve the full notice text, so the data elements, dollar scale and length of the agreement are not confirmed here. Who it hits: beneficiaries and providers whose care is billed to both systems. Confidence: Med on purpose per the Federal Register summary; Low on scope. Sources: Federal Register, Privacy Act matching program notice (2026-21491).