Colorado's Medicaid program has been overpaying transportation providers in the Denver area millions of dollars each year since the Department of Health Care Policy and Financing instructed them to bill van service accommodating extra-large wheelchairs using the code for specialty ambulance transport. The higher code was little used until 2023, when other non-emergency medical transportation rates increased, along with fraud claims. The instructions were corrected in November, and the state is expected to save more than $60 million in fiscal 2026-27 alone. The state is also investigating whether upcoding or other abusive practices occurred.

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Pankaj Merchia, a former physician in Massachusetts and Florida, has been convicted of health care fraud, money laundering and tax evasion. Prosecutors said Merchia ran two health care fraud schemes related to CPAP and BiPAP machines. Merchia allegedly billed for rentals for patients he hadn't seen in years, and when claims for equipment provided to his brother were rejected, Merchia set up a new business and submitted the claims, according to prosecutors.

Two people have been accused of defrauding Florida's Medicaid program of more than $70,000, according to state Attorney General James Uthmeier. Alexander McKinnie allegedly submitted false claims worth more than $65,000 for non-emergency medical transportation that was never provided. Kara Morrison allegedly assisted McKinnie by submitting $7,000 worth of false claims.

Leticia Gallarzo was sentenced to serve more than six years in federal prison for identity theft and practicing medicine without a license. Gallarzo pleaded guilty to allegations that she created a fake nurse's license and credentials and worked as a nurse in Michigan and Los Angeles and as a physician's assistant under another fake identity in Chicago. Gallarzo's attorney says she has a history of mental illness.

Artificial intelligence is streamlining processing of veterans' claims at the Department of Veterans Affairs and has helped reduce the claims backlog by more than 57%, according to a case study by Booz Allen Hamilton. The document processing system, based on Amazon's Textract, uses optical character recognition and machine learning to create a searchable repository of veterans' documents, and a search function enables service representatives to filter records and find relevant information quickly.

The No Surprises Act was enacted in 2022 to shield patients from unexpected medical bills that previously resulted from out-of-network care during emergencies or at in-network hospitals. The law removes patients from disputes between insurers and providers, mandating a negotiation period followed by a structured arbitration process if no agreement is reached. While the act has helped protect patients from direct billing shocks, industry experts argue that the resulting disputes between insurers and providers have escalated, raising questions about unintended financial consequences for the broader health care system.

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