Schedule

• Reimbursement systems applicable to Part A and B providers
• Beneficiary enrollment, coverage, and benefits
• Provider enrollment and certification
• Conditions of participation and payment
• Governance and structure: CMS, ROs (and the transition to PEOGs), and MACs
• How Parts A and B impact transactions
• Congressional legislation, agency guidance, and key compliance resources

This session will provide an update on key changes affecting Medicare and Medicaid reimbursement that occurred during 2025 and in the early days of 2026, including the following:

• Key hospital, physician and other provider / supplier payment rules from the 2025 rulemaking cycle
• CMS Innovation Center priorities, new and updated alternative payment models and other initiatives in value-based care
• Developments in civil, criminal and administrative enforcement along with recent program integrity activities
• Key court cases and legal challenges affecting reimbursement and compliance
• of administration policy initiatives, executive orders, related litigation and proposed rules
• New or expanded policy changes, such as provider-based attestations, provider taxes, 340B program, telehealth, implications of OBBBA, Medicare Advantage developments, Medicare Drug Price negotiation, conditions of participation, Medicare enrollment, OIG guidance and more

• How the Medicaid program is changing in a particular state and nationally
• How the HR1 is affecting their programs and how they are responding to it
• Innovative features of the particular State's Medicaid program potentially addressing such items as social determinants of health care (SODH), managed care organizations, the opioid crisis, behavioral health, APMs, long term care and home and community-based care, and 1332 and 1115 waivers
• If and how public health issues are affecting their various programs, e.g. staffing shortages, and potentially what lessons have they learned from the COVID pandemic and the actions the state is taking to prepare for future pandemics

The Medicare Cost Report continues to be a required complex filing for hospitals seeking Medicare reimbursement. The cost report also remains an important source of data for most providers and is a frequent basis for regulatory and litigation issues for health care lawyers. This introductory session provides a practical overview of the hospital cost report (Form CMS-2552) for attendees who are not yet familiar with the forms comprising the cost report. We will cover how the report is organized and flows, the basics of the remaining cost-based reimbursement calculations, and the schedules that contain critical data. Topics covered:

• Forms, filings, and deadlines: What is filed, by whom, when, and what happens next
• Report structure and flow: How the major schedules flow through the cost report
• Overhead step‑down and cost‑based reimbursement: Core concepts and calculations
• Key schedules and data points: Settlement, outlier reconciliations, financial statements, and related exhibits
• Protested Items, disputes, appeals, and litigation primer: How cost reporting issues translate into administrative appeals and federal court litigation

We will cover key issues distressed Medicare and Medicaid providers should follow in the new administration, including:

• Developments in Medicare/Medicaid recoupment and offset
• Meeting the challenge of Medicare suspensions
• Recent cases on bankruptcy jurisdiction in Medicare and Medicaid payment disputes
• Transfer of Medicare (Part A) and Medicaid provider agreements in bankruptcy
• The Government's use of the CHOW process in bankruptcy

• The structure and purpose of DGME, IME, and GME caps
• The Need for Additional Graduate Medical Education and the Impact on the US Healthcare Delivery System
• Operational decision making that affects GME reimbursements and program funding
• Payment metrics associated with the current funding of US Graduate Medical Education programs that are favorable to Graduate Medical Education
• State-level strategies for expanding GME funding and capacity and geographic distributions of Medicare supported GME positions

• Applicability of Traditional Medicare Rules and Policies
• Internal Coverage Criteria in Medical Review
• Prior Authorization: Processes, Requirements, and Limitations
• Implications of Artificial Intelligence (AI) and the CMMI Wasteful and Inappropriate Service Reduction (WISeR) Model

• Recent material 340B developments
• Myths and truths about 340B Program compliance and oversight obligations
• Examples of recent federal and state enforcement priorities
• Best practices for in-house legal teams to support 340B Program operations
• Examples of hypothetical 340B scenarios and practical guidance for in-house responses

• High-level overview of the Medicare Cost Report and its continued relevance for hospital reimbursement challenges in the Medicare Program prospective payment system and value-based payment system eras
• The elements of the “standardized rate” used as the basis for applying Medicare’s inpatient PPS, including an overview of outlier payments, and what may or may not be challenged by hospitals
• The implications of “predicate errors” that may live on in current payment amounts various and the strategies and challenges appealing them
• Evaluate the cost report reopening process and its opportunities and limitation for addressing payment errors, including retroactive rule changes

• Medicare compliance concerns that continue to vex the industry from a veteran compliance officer and compliance counsel
• APPs–compliance risks abound
• Not all trainees are created equal–compliance issues for teaching physicians, residents, and students
• Recommendations on where we go from here

• Overview of Medicare's payment rules for nursing and allied health programs
• The provider-operated criteria and the friction with hospital operations and accreditation standards
• Common audit requirements and expectations
• Statutory and regulatory exceptions to the provider-operated rules
• Litigation implicating nursing and allied health reimbursement, including pending and recently decided cases.
• Proposed legislative and regulatory changes to the nursing and allied health payment rules

• Provider-Based Status Fundamentals
• Threading the needle between provider-based compliance and systematizing
• Implementation of the CAA 2026 attestation requirement
• Using provider-based status to protect 340B eligibility
• Implications of CMS’s site neutrality rule for provider-based status
• Updates on the drug acquisition cost survey

• The major shift since 2025 in policy priorities related to health equity for federal government funding and changes in the federal and state legal and regulatory landscape, including the anti-discrimination provisions in Section 1557 of the Affordable Care Act and their related regulations, the US Department of Health and Human Services Assurance of Compliance, and other federal certification requirements
• Notwithstanding these changes, many health care organizations and professionals remain deeply committed to identifying disparities in health outcomes and access to care, understanding the systemic barriers and other factors that may contribute to those disparities, and developing innovative solutions (such as digital health or community-based services) to eliminate them
• This session will give real-life examples of how ongoing initiatives to improve health equity can be aligned with the evolving federal policy and legal landscape and other practical tips for health care organizations seeking to ensure compliance in an ever-changing environment

• Brief overview of Medicaid, the largest US health coverage program
• The background on Medicaid's structure, history, evolution, and current legal landscape
• Assess recent federal legislative and administrative developments shaping the future of Medicaid and how to navigate these changes, including the changes made by the One Big Beautiful Bill Act
• Understand other significant Medicaid changes, including major CMS policy announcements and the recent Medina Supreme Court decision

• Recent developments in administrative law
• CMS Enforcement Tools–Payment Suspensions, Moratoria, Billing Privileges Revocations
• OIG Enforcement Tools–Exclusions and Civil Monetary Penalties

• Analysis and implications of the rulings in Texas and Florida federal courts on provider tax requirements
• Challenge to HR 1 restriction of Medicaid payments to Planned Parenthood and
• Planned Parenthood's eligibility to enroll in Medicaid
• Important cases regarding Medicaid benefits, especially for disabled enrollees
• Collection of payments against estates and lien issues

• Inpatient hospital payment update
• Wage index issues
• Uncompensated care payments
• Other Noteworthy Provisions in the IPPS Final Rule
• Beyond the IPPS: Key Policies in the OPPS Final Rule

• Frame the report-and-return requirement and analyze self-audit obligations under the federal Overpayment Statute, including when an overpayment is "identified"
• The Overpayment Statute's intersection with the False Claims Act
• Address critical distinctions and considerations for overpayments in the Medicare FFS versus Medicare Advantage contexts
• Consider the role and relative weight of statutory, regulatory, and subregulatory agency guidelines, reflecting on the significance of Loper Bright and the current deregulatory environment
• Discuss several compliance and overpayment scenarios to assess likely conditions of payment, evaluate available deference and rulemaking related defenses, and consider implications for scienter arguments
• Distill practical takeaways for providers conducting internal investigations and defending false claims allegations

• Introduction of Board members
• Board decisions
• Jurisdiction
• Hearings
• Case inventory
• Board initiatives
• Board Rules and mandatory electronic filing
• Evaluation of decision process
• Observations from the Board

Recent years have seen major expansions in behavioral health coverage in both Medicare and Medicaid. Medicare has traditionally covered a very limited range of behavioral health clinicians' services and substance use disorder (SUD) interventions, but has expanded its reach to cover more clinicians' services and a wider range of SUD services. Medicaid is functioning as an engine of change in behavioral health policy, with the certified community behavioral health clinic (CCBHC) model, in particular, gaining national momentum. We will discuss:

• A survey of promising developments and challenges in behavioral health coverage and payment in Medicare and Medicaid. We will discuss how these trends impact various provider sectors, and how medical providers and practices may partner with behavioral health providers in their communities to make these new or expanded services more widely available
• The impact of budgetary issues on the expanded behavioral health services under Medicare and Medicaid, including the status of 1115 demonstration projects, and the potential impact of the community engagement requirements included in the One Big Beautiful Bill Act (Pub. L. No. 119-21)
• Services and payment methodologies covered will include Medicaid CCBHC services; Medicare intensive outpatient program (IOP) services; Medicare opioid treatment program (OTP) services; the expansion of Medicare Part B-covered behavioral health clinician services; school-based mental health services; and medication-assisted treatment (MAT) for opioid use disorder in Medicaid

• An overview of the final Medicare Physician Fee Schedule for 2026
• Implications of the changes contained in the final MPFS
• Trending topics in the MPFS
• Other new developments and realities of physician payment
• What we should expect in 2027

• Imminent changes to the uninsured population and its impact on state and federal DSH reimbursement
• How hospitals articulate various forms of patient financial assistance in financial assistance policies
• Best practices to fully recognize and report allowable uncompensated care costs
• Issues with federal and state uncompensated care cost reporting instructions and audits

This session will provide an overview of rules governing Medicaid payments to providers, directly and through managed care plans, and critical mechanisms for supplementing and directing Medicaid payments to support policy goals. In addition to an overview of the payment authorities outlined below, we will touch on the latest trends in federal Medicaid provider payment policy, including changes under the federal Working Families Tax Cut legislation passed in July 2025 and its implementation. Our overview will include the following authorities:

• Medicaid disproportionate share hospital (DSH) payments
• Non-DSH Medicaid fee for service supplemental payments
• Medicaid 1115 demonstration waiver payments
• Medicaid managed care directed payments

This program will address the practical differences between hospital payments, policies, and procedures when MCOs are involved. The practical hospital perspectives include an accomplished attorney representing hospitals on managed care payment related issues and Chief financial officer providing insight into the operational, strategic and reimbursement considerations of FFSs vs. MCOs. Presentation will include:

• The history, evolution, and significance of Medicare managed care
• Payment differences identified through including insurance payments, cost sharing, Medicare cost report settlement and value-based purchasing
• The importance of careful contracting including retroactive settlement provisions and denial management
• Current regulatory environment and upcoming changes
• Practical operational and strategic considerations that contemplate the current state of the industry

Leveraging the perspective and experience of both a private practice Medicare reimbursement litigator and a DOJ litigator, this session will cover:

• The past year's significant Federal court cases or decisions affecting Medicare reimbursement, including the result and implications of the Supreme Court's DSH decision in Advocate Christ v Becerra, as well as significant ongoing litigation challenging one of the building blocks of Medicare inpatient payments, i.e., the standardized amount
• Issues particularly pertinent to Medicare litigation such as agency deference post-Chevron, jurisdiction, substantive and procedural challenges, and remedies
• What recent decisions tell us about the strengths and weaknesses of ongoing Medicare reimbursement appeals

• Recent developments in CMS's program integrity efforts
• Recent priorities and developments in HHS-OIG enforcement efforts
• Recent priorities and developments in DOJ civil and criminal enforcement and False Claims Act case law"

• Inpatient hospital payment update
• Wage index issues
• Uncompensated care payments
• Other Noteworthy Provisions in the IPPS Final Rule
• Beyond the IPPS: Key Policies in the OPPS Final Rule

• Legal framework/guidance for Medicare Appeals
• Lifecycle of an Appeal
• Update from the Office of Medicare Hearings and Appeals
• Update from the Medicare Appeals Council/DAB
• Case example
• Special issues

• Overview of the administration and operation of Medicaid managed care
• Fiscal accountability in Medicaid managed care (capitation/risk adjustment, medical loss ratio, value-based payments, directed payments)
• Proliferation of state directed payment programs & growth in spending
• Case studies illustrating Impact of OBBBA on state directed payment program limits and financing, present and future
• The role of state procurement of Medicaid managed care payors

This session will provide an overview of such safety net health care providers as federally qualified health centers, rural health clinics, and safety net hospitals (including DSH hospitals, critical access hospitals and Rural Emergency Hospitals) together with recent developments affecting these provider types. The anticipated impacts of the OBBBA on these providers will be addressed along with the OBBBA's new approximately $50 billion rural hospital grants program.

• Applicability of Traditional Medicare Rules and Policies
• Internal Coverage Criteria in Medical Review
• Prior Authorization: Processes, Requirements, and Limitations
• Implications of Artificial Intelligence (AI) and the CMMI Wasteful and Inappropriate Service Reduction (WISeR) Model

• Provider-Based Status Fundamentals
• Threading the needle between provider-based compliance and systematizing
• Implementation of the CAA 2026 attestation requirement
• Using provider-based status to protect 340B eligibility
• Implications of CMS’s site neutrality rule for provider-based status
• Updates on the drug acquisition cost survey

• Problem: Waste in health care can not only harm patients but also contributes to up to 25% of health care spending in the United States. Wasteful, low-value services often have limited clinical evidence of effectiveness, may not align with an individual’s specific health condition or needs, or can lead to complications and further unneeded services
• Solution: The WISeR Model will help reduce clinically unsupported care by working with companies experienced in using enhanced technologies to expedite and improve the review process for a pre-selected set of services that are vulnerable to fraud, waste and abuse
• Outcomes: The WISeR Model will help ensure people with Medicare receive the most appropriate care that supports the best health outcomes while decreasing costs and easing administrative burden on providers and suppliers who go through the prior authorization process
• Strategy: The WISeR Model empowers patients to partner with their health care providers on the most clinically appropriate care plan; protects the taxpayer by decreasing fraud, waste and abuse; and focuses providers on care that has the most impact on the well-being of people with Medicare

• History and overview of hospital at home and home-based care
• Recent developments on coverage and reimbursement for hospital at home services
• Other care at home–the continued proliferation of home-based care models
• Real world experience–practical implications and experience from the development and implementation of a hospital at home program

• Imminent changes to the uninsured population and its impact on state and federal DSH reimbursement
• How hospitals articulate various forms of patient financial assistance in financial assistance policies
• Best practices to fully recognize and report allowable uncompensated care costs
• Issues with federal and state uncompensated care cost reporting instructions and audits

• How PAC discharge decisions can impact patient outcomes and financial performance in risk-based payment models
• Legal requirements for creating compliant high-value PAC networks
• Regulatory, legal, and operational issues providers encounter when discharging patients to high-value PAC networks
• The data and process used to identify high-value PAC providers and recruit them to participate in the network
• Strategies for engaging providers in care redesign related to PAC networks and discharge decisions

• The structure and purpose of DGME, IME, and GME caps
• The Need for Additional Graduate Medical Education and the Impact on the US Healthcare Delivery System
• Operational decision making that affects GME reimbursements and program funding
• Payment metrics associated with the current funding of US Graduate Medical Education programs that are favorable to Graduate Medical Education
• State-level strategies for expanding GME funding and capacity and geographic distributions of Medicare supported GME positions

• Overview of Medicare's payment rules for nursing and allied health programs
• The provider-operated criteria and the friction with hospital operations and accreditation standards
• Common audit requirements and expectations
• Statutory and regulatory exceptions to the provider-operated rules
• Litigation implicating nursing and allied health reimbursement, including pending and recently decided cases.
• Proposed legislative and regulatory changes to the nursing and allied health payment rules

• The major shift since 2025 in policy priorities related to health equity for federal government funding and changes in the federal and state legal and regulatory landscape, including the anti-discrimination provisions in Section 1557 of the Affordable Care Act and their related regulations, the US Department of Health and Human Services Assurance of Compliance, and other federal certification requirements
• Notwithstanding these changes, many health care organizations and professionals remain deeply committed to identifying disparities in health outcomes and access to care, understanding the systemic barriers and other factors that may contribute to those disparities, and developing innovative solutions (such as digital health or community-based services) to eliminate them
• This session will give real-life examples of how ongoing initiatives to improve health equity can be aligned with the evolving federal policy and legal landscape and other practical tips for health care organizations seeking to ensure compliance in an ever-changing environment

• Federal financial participation
• The non-federal share and permissible sources of state funding
• Intergovernmental transfers (IGTs) and certified public expenditures (CPEs)
• Provider tax rules, recent litigation, and CMS guidance
• The OBBBA's impact on provider taxes and Medicaid financing

• The history and evolution of Medicare prospective payment systems
• The currency and relevance of the factors used to determine payment rates and hospital specific adjustments
• Examples of how recent and active litigation influences payment policy
• The adequacy of current payment rates against the back drop of a hospital Medicare margin calculation
• How current payment methodologies may not align with hospital operations and care delivery mechanisms
• Connection between Medicare payment methods and how other payers may use the data to their advantage
• The practicalities of various rebasing scenarios

Leveraging the perspective and experience of both a private practice Medicare reimbursement litigator and a DOJ litigator, this session will cover:

• The past year's significant Federal court cases or decisions affecting Medicare reimbursement, including the result and implications of the Supreme Court's DSH decision in Advocate Christ v Becerra, as well as significant ongoing litigation challenging one of the building blocks of Medicare inpatient payments, i.e., the standardized amount
• Issues particularly pertinent to Medicare litigation such as agency deference post-Chevron, jurisdiction, substantive and procedural challenges, and remedies
• What recent decisions tell us about the strengths and weaknesses of ongoing Medicare reimbursement appeals

• Recent developments in CMS's program integrity efforts
• Recent priorities and developments in HHS-OIG enforcement efforts
• Recent priorities and developments in DOJ civil and criminal enforcement and False Claims Act case law"

• Ongoing implementation of the Inflation Reduction Act (IRA):
  • Status of the negotiation program, inflation rebates, and Part D redesign
  • Overlap with other federal programs
• Trump Most Favored Nation (MFN) policy:
  • Implications of the Generous, Globe, and Guard payment models
  • TrumpRx
  • Outlook and next steps (crystal ball)
• 340B program reform:
  • Status of the rebate model
  • Learnings from Administrative Dispute Resolution (ADR) decisions

This session will provide the audience with an overview of the wage index system as well as a strategic roadmap for navigating wage index complexities. We will explore calculation methodologies, compliance risks, and reclassification strategies such as MGCRB and Urban-to-Rural conversions. Attendees will gain actionable insights to align operational accuracy with organizational goals and optimize reimbursement opportunities. We will discuss:

• How the wage index impacts Medicare payments
• How the Medicare Wage Index is calculated and identify reporting risks and opportunities for hospitals
• Critical keys to success when approaching Medicare Wage Index and rural reclassifications
• The critical timelines and requirements for applying for special provider statuses used in MGCRB reclassifications
• The key elements involved in completing the Occupational Mix Survey accurately

• Recent material 340B developments
• Myths and truths about 340B Program compliance and oversight obligations
• Examples of recent federal and state enforcement priorities
• Best practices for in-house legal teams to support 340B Program operations
• Examples of hypothetical 340B scenarios and practical guidance for in-house responses

• An overview of the final Medicare Physician Fee Schedule for 2026
• Implications of the changes contained in the final MPFS
• Trending topics in the MPFS
• Other new developments and realities of physician payment
• What we should expect in 2027

• Office of Hearings Case and Document Management System (“OH CDMS”) updates
• Jurisdictional, procedural, and case management updates
• Applying best practices before the Board
• Emerging trends

• Analysis and implications of the rulings in Texas and Florida federal courts on provider tax requirements
• Challenge to HR 1 restriction of Medicaid payments to Planned Parenthood and
• Planned Parenthood's eligibility to enroll in Medicaid
• Important cases regarding Medicaid benefits, especially for disabled enrollees
• Collection of payments against estates and lien issues

• Frame the report-and-return requirement and analyze self-audit obligations under the federal Overpayment Statute, including when an overpayment is "identified"
• The Overpayment Statute's intersection with the False Claims Act
• Address critical distinctions and considerations for overpayments in the Medicare FFS versus Medicare Advantage contexts
• Consider the role and relative weight of statutory, regulatory, and subregulatory agency guidelines, reflecting on the significance of Loper Bright and the current deregulatory environment
• Discuss several compliance and overpayment scenarios to assess likely conditions of payment, evaluate available deference and rulemaking related defenses, and consider implications for scienter arguments
• Distill practical takeaways for providers conducting internal investigations and defending false claims allegations

• The history and evolution of Medicare prospective payment systems
• The currency and relevance of the factors used to determine payment rates and hospital specific adjustments
• Examples of how recent and active litigation influences payment policy
• The adequacy of current payment rates against the back drop of a hospital Medicare margin calculation
• How current payment methodologies may not align with hospital operations and care delivery mechanisms
• Connection between Medicare payment methods and how other payers may use the data to their advantage
• The practicalities of various rebasing scenarios

This session will provide an overview of such safety net health care providers as federally qualified health centers, rural health clinics, and safety net hospitals (including DSH hospitals, critical access hospitals and Rural Emergency Hospitals) together with recent developments affecting these provider types. The anticipated impacts of the OBBBA on these providers will be addressed along with the OBBBA's new approximately $50 billion rural hospital grants program.

• History and overview of hospital at home and home-based care
• Recent developments on coverage and reimbursement for hospital at home services
• Other care at home–the continued proliferation of home-based care models
• Real world experience–practical implications and experience from the development and implementation of a hospital at home program