Departments Finalize Federal No Surprises Act IDR Operations Rule: What Payers, Plans, and Providers Need to Know

May 31, 2026

Health care providers, group health plans, their plan sponsors and fiduciaries, and their claims and billing service providers should review and update their processes for handling out-of-network provider charge disputes in response to the CMS, Federal Independent Dispute Resolution Operations; Final Rules (CMS-9897-F, full text PDF) released on May 28, 2026 to implement the No Surprises Act (“NSA”). See also CMS, Federal Independent Dispute Resolution Operations Final Rule (Fact Sheet); HHS, Federal Rule Takes Aim at Health Care Bureaucracy, Reducing Dispute Fees, and Boosting Transparency (Press Release, May 28, 2026).

The rule issued by the Departments of Health and Human Services, Labor, and the Treasury (the “Departments”), acting through the Centers for Medicare & Medicaid Services (“CMS”) and joined by the Office of Personnel Management (“OPM”), overhauls the operational mechanics of the federal arbitration process that the NSA requires group health plans, issuers, Federal Employees Health Benefits carriers (“payers”), and out-of-network providers, facilities, and air ambulance providers (“providers”) use to resolve out-of-network payment disputes. (CMS Fact Sheet; HHS Press Release). Also see CMS, No Surprises Act — Overview of Rules & Fact Sheets.

According to the Departments, the Federal IDR process has received more than 5 million disputes since launching in April 2022—far beyond projections, generating delays, backlogs, and unnecessary cost. (HHS Press Release). Much of the rule targets a recurring problem: ineligible disputes clogging the pipeline because parties cannot readily tell, early on, which claims actually qualify for federal arbitration.

Below is a practical summary of the key changes and, importantly, the staggered dates on which they take effect.

IDR Administrative Fee Drops to $15

For parties weighing whether to use the process, the most immediate change is cost. The per-party, per-dispute administrative fee falls from $115 to $15—a reduction of more than 85%—while the program remains self-sustaining as the statute requires. The $15 fee applies regardless of the amount in dispute or whether the dispute is ultimately found eligible. (HHS Press Release; CMS Fact Sheet).

The rule also codifies existing guidance: if a party fails to pay the administrative fee or the certified IDR entity fee by the time its offer is due, that offer will not be considered received—but the party remains liable for the fees. The Departments further clarified their authority to pursue unpaid administrative fees consistent with federal debt collection laws. (CMS Fact Sheet).

Improving Communication Up Front (CARCs and RARCs)

A central theme of the final rule is forcing better information exchange before a dispute ever reaches arbitration. The rule requires payers to use specific claim adjustment reason codes (“CARCs”) and remittance advice remark codes (“RARCs”) on any paper or electronic remittance advice sent to an entity with which the payer has no contractual relationship, signaling whether a claim is or is not subject to the NSA’s surprise-billing provisions and the federal IDR process. (CMS Fact Sheet).

Payers must also disclose additional identifying information with the initial payment or notice of denial of payment, including:

  • The legal business name of the plan, issuer, or FEHB carrier,
  • The plan sponsor’s legal business name where applicable, and
  • The new IDR registration number (discussed below), and
  • Include a statement explaining that providers must notify the Departments to initiate open negotiation. (CMS Fact Sheet).

Restructured Open Negotiation

The final rule meaningfully tightens the 30-business-day open negotiation period. Under the final rule, a party must submit an open negotiation notice through the Federal IDR portal to both the other party and the Departments, with expanded required content elements. The 30-business-day clock now begins when that notice and the payment remittance or denial are submitted through the portal. The rule also creates a new open negotiation response notice, which the receiving party must furnish by the 15th business day of the negotiation period. (CMS Fact Sheet).

These mechanics are designed to document clear start and end dates in the portal and cut down on disputes advancing to arbitration without genuine negotiation.

New Batching Rules—and a 50-Item Cap

The rule revises when items and services may be combined into a single “batched” dispute. Batching is permitted where the items and services are:

  • Furnished to a single patient on the same or consecutive dates of service and billed on the same claim form (a patient encounter);
  • Furnished to one or more patients and billed under the same service code or a comparable code under a different procedural code system (e.g., CPT and HCPCS); or
  • Anesthesiology, radiology, pathology, and laboratory services furnished to one or more patients under service codes within the same Category I CPT code section, as specified in Departmental guidance.

Critically, the rule imposes a hard ceiling of 50 qualified IDR line items per batched dispute, so certified IDR entities can make timely determinations and forecast their costs. (CMS Fact Sheet).

Hard Deadline on Eligibility Determinations

Eligibility review has been the single biggest source of delay. The rule now requires certified IDR entities to determine eligibility within five business days of final entity selection and to notify both parties and the Departments.

To support eligibility, conflict-of-interest, and payment determinations, parties must respond to a certified IDR entity’s request for additional information within 5 business days. If a party does not respond, the entity proceeds without the information where possible, or closes the dispute where it is not. (CMS Fact Sheet).

New IDR Registry for Payers

To solve the persistent problem of providers being unable to identify the correct payer or contact, the final rule requires payers subject to the federal IDR process to register with the Departments and supply general information about how the process applies to their coverage.

The registry is part of the broader IDR Gateway—a centralized platform for starting, tracking, and managing disputes that the Departments will roll out in phases beginning in 2026. (HHS Press Release).

Each registrant receives an IDR registration number that parties can use to confirm eligibility, and that the Departments, OPM, and certified IDR entities can access for enforcement and eligibility purposes. (CMS Fact Sheet).

Extenuating Circumstances

The final rule expands the extenuating circumstances under which IDR timeframes may be extended to include events causing systemic processing delays, such as an unforeseen volume of disputes or portal system failures, and commits the Departments to posting public notice of any such system-wide extensions. Parties also may still request individual extensions through the portal. (CMS Fact Sheet).

Staggered Effective Dates

Covered parties must mind the staggered effective dates of the various components of the final rule. Compliance planning here is complicated by a phased rollout. Based on the Departments’ applicability discussion:

  • CARC/RARC communication and the QPA disclosure modifications take effect on the rule’s effective date, with implementing guidance to follow.
  • The lower $15 administrative fee applies to disputes initiated on or after 5 business days after publication of the final rule (the Departments invoked good cause to waive the APA’s delayed-effective-date requirement).
  • The fee-nonpayment procedures apply on the effective date.
  • The revised batching definition applies to disputes with open negotiation periods beginning 90 days after the effective date.
  • Most IDR process changes (open negotiation, IDR initiation, certified IDR entity selection, eligibility review, batched/bundled treatment, offer and payment-determination deadlines, and certain withdrawals) apply to disputes with open negotiation periods beginning 90 days after the Departments issue guidance that the supporting functionality is available.
  • The IDR Registry provisions become applicable 90 business days after the Departments announce that the registry functionality is available. (CMS Fact Sheet)

Litigation Backdrop: Courts Keep Rejecting Payers’ Collateral Attacks on IDR Awards

The final rule arrives against a wave of litigation in which payers—frustrated by the very volume problem the rule targets—have tried, and so far failed, to undo unfavorable IDR outcomes in court. Although payers largely pushed for the NSA IDR process, today’s, providers have used the rules more effectively than payers. Payers have struggled to effectively operationalize their response to the NSA IDR process. Payers have brought suits complaining that providers and their billing intermediaries have overwhelmed the system by submitting large numbers of allegedly ineligible disputes, inflating out-of-network reimbursement at plans’ (and ultimately consumers’) expense. Providers have disputed these allegations.

The most recent decision came on May 22, 2026, when the U.S. District Court for the Eastern District of Texas dismissed, with prejudice, all seven claims that Blue Cross Blue Shield of Texas (a division of Health Care Service Corporation) brought against HaloMD, the largest filer of IDR disputes, and affiliated provider defendants. BCBS Texas accused HaliMD and the providers in that suit of RICO, fraud, fraudulent inducement, negligent misrepresentation, and related state-law claims, alleging that the defendants gamed the federal and Texas IDR processes by attesting to eligibility on disputes that were not eligible—seeking, by the defense’s account, to unwind tens of thousands of binding IDR awards.

The court treated those Blue Cross claims as damages tethered to the IDR awards themselves and therefore an impermissible collateral attack on determinations Congress made binding and largely insulated from judicial review. The court also declined to read the injunctive-relief request as a freestanding cause of action. Blue Cross Blue Shield of Texas v. HaloMD, LLC, No. 5:25-cv-00132-RWS (E.D. Tex. May 22, 2026).

The Blue Cross Blue Shield of Texas v. HaloMD, LLC ruling tracked a nearly identical outcome weeks earlier in the April 2026 suit by Anthem Blue Cross (Elevance Health’s California subsidiary) against HaloMD and affiliated providers. In Anthem Blue Cross Life & Health Ins. Co. v. HaloMD LLC, No. 8:25-cv-01467-KES (C.D. Cal. 2026), the U.S. District Court for the Central District of California dismissed without leave to amend the payer’s suit, reasoning that the No Surprises Act forecloses judicial review of IDR payment determinations on all but narrow grounds, and that a certified IDR entity’s payment determination necessarily incorporates the threshold eligibility determination—closing the door on the payer’s theory that it was challenging “eligibility” rather than the award. 

These were not isolated results. With the Blue Cross Blue Shield of Texas Eastern District of Texas decision, four federal courts already rejected comparable insurer attempts to relitigate IDR awards within roughly six weeks, with parallel dismissals also reported in the Middle District of Florida and the Eastern District of Pennsylvania. The statutory anchor running through the decisions is the NSA’s limitation on judicial review of IDR determinations in 42 U.S.C. § 300gg-111.

The practical lesson is twofold.

  • For providers and their billing partners, the binding nature of IDR awards remains a meaningful shield, but the same volume-and-eligibility concerns driving this litigation are now embedded in the regulatory framework, which is designed to keep ineligible disputes out of the process in the first place.
  • For payers, courts are signaling that collateral litigation is a poor substitute for fixing eligibility and communication problems at the front end—precisely what the new operational rule attempts to do through CARCs/RARCs, portal-documented open negotiation, the five-business-day eligibility deadline, the 50-item batching cap, and the IDR Registry.

Key Takeaways for Plans, Payers, and Employers

For plan sponsors, self-insured employers, issuers, and their third party administrators, the action items are concrete. Payers must begin mapping the CARC/RARC requirement into their remittance and EDI workflows, confirm that initial-payment and denial disclosures will carry the new legal-name and registration-number elements, and prepare to register in the IDR Registry once functionality opens. Plan sponsors and fiduciaries should review contracts to ensure contracts appropriately assign responsibility and accountability of their third party administrator or other service providers, and review the reasonability and appropriateness of processes and compensation keeping in mind that the Labor Department views NSA administration and selection, oversight and management, and compensation of vendors as fiduciary conduct.

Both payers and providers should revisit internal protocols so open negotiation notices and responses are submitted through the portal within the new deadlines, and so requests for additional information from certified IDR entities are answered within the five-business-day window. Given the staggered applicability dates, organizations should watch for the Departments’ implementing guidance, which will control when several of the operational changes actually bind.

As this provides only a high-level summary of a lengthy and technical rulemaking, plans, their sponsors, fiduciaries and vendors, payers, and providers should review the full final rule and consult counsel before relying on any single provision, particularly given the phased effective dates and forthcoming guidance.

For Help or More Information

The author of this update, Cynthia Marcotte Stamer advises health care providers, employer and union sponsored self-insured group heath plans, their sponsors and fiduciaries, insurers, their service and technology providers, and other health industry clients on NSA and other coverage and payment, enrollment, compliance programs, government investigations, transaction due diligence, reimbursement compliance and disputes, audits and investigations, and other legal and operational compliance and risk management and legislative and regulatory affairs. She is available to assist your organization in assessing the impact of these developments and navigating the compliance and strategic steps that follow. For more information about these  or other health care, managed care and other health benefits, or other health care developments, please contact Ms. Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.

About the Author

Peer recognized as “Top Rated Lawyer” and “LEGAL LEADER™ “Top Rated Lawyer” and “Best Lawyer” for her work in Health Care Law, Labor and Employment Law; ERISA & Employee Benefits,” and “Business and Commercial Law,” Cynthia Marcotte Stamer is an A Martindale-Hubble “AV-Preeminent” (Top 1%) attorneys board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for her more than 35 years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications including leading edge work on PBM, pharmacy and pharmaceutical and other health care, managed care, insurance, and insured and self-insured contracting, design, administration and regulation.. 

Author of numerous highly regarded works on health care fraud and other compliance, risk management and operations,  Chair of the Tort Trial and Insurance Practice Section Medicine and Law Committee, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, the ABA International Section Life Sciences Committee and the former Group Chair and Welfare Benefit Committee Co-Chair of the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health industry legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her career has focused heavily on working with hospitals, health care systems, long term care, rehabilitation, home health, hospice, clinics, and other health care organizations; physician and other provider organizations and practitioners; accreditation, medical staff, peer review, and quality committees and organizations; billing, audit, practice management, utilization management, EMR, claims, payroll and other technology, billing and reimbursement and other services and product vendors and services organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; DME; health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations; consultants; products and solutions consultants and developers; investors; managed care organizations, self-insured health and other employee benefit plans, their sponsors, fiduciaries, administrators and service providers, insurers and other payers, health industry advocacy and other service providers and groups and other health and managed care industry clients as well as federal and state legislative, regulatory, investigatory and enforcement bodies and agencies on billing and reimbursement, government investigations and enforcement, and other legal and operational compliance and risk management, performance and workforce management, regulatory and public policy, and other legal and operational concerns. 

Author of a multitude of highly regarded publications and presentations,  Ms. Stamer is widely recognized for her thought leadership on these and other health care, managed care and other health plan,and other health industry matters.  In addition, Ms. Stamer contributes her time and leadership to numerous policy, professional, civil and other organizations including service as the, the American Bar Association (ABA) International Section Life Sciences Committee Vice Chair, a Scribe for the ABA Joint Committee on Employee Benefits (JCEB) Annual OCR Agency Meeting and a former Council Representative, Past Chair of the ABA Managed Care & Insurance Interest Group, former Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, and a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her extensive publications and thought leadership as well as leadership involvement in a broad range of other professional and civic organizations. For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general information and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation considering the specific facts and circumstances presented in their unique circumstance at the particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author reserves the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law constantly and often rapidly evolves, subsequent developments that could impact the currency and completeness of this discussion are likely. The author and Solutions Law Press, Inc. disclaim and have no responsibility to provide any update or otherwise notify anyone of any  fact or law specific nuance, change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2026 Cynthia Marcotte Stamer. Non-exclusive right to republish granted to Solutions Law Press, Inc.™ For information about republication, please contact the author directly. All other rights reserved.

Leave a Comment » | ambulance, balance billing, Emergency Care, Employee Benefits, Employer, ERISA, Health Care, Health Care, Health care coding, Health Care Finance, Health Care Provider, health care reimbursement, Health Insurance, Health IT, Health Plan, Health Plans, healthcare, Hospital, Hospital, hospitals, Independent Dispute Resolution, no surprises act, Physician, Reimbursement, surprise billing | Permalink
Posted by Cynthia Marcotte Stamer

CMS Imposes Nationwide Enrollment Moratoria on Hospices and Home Health Agencies; Issues New Medicaid State Directed Payment Limits

May 18, 2026

Hospices and home health agencies, referring providers, states, and patients and their caregivers should prepare to cope with the likely impacts of a new Medicare program enrollment moratorium on new hospice and home health agencies and changes in Medicare and Medicaid reimbursement rules announced last week as part of a new federal antifraud initiative.

KEY TAKEAWAYS: CMS has imposed immediate nationwide six-month enrollment moratoria for home health agencies and hospices in Medicare, effective May 13, 2026. Separately, CMS has issued guidance capping Medicaid State Directed Payments at or below Medicare rates. Existing enrolled providers are unaffected by the moratorium and may continue billing with the understanding that they must ensure their billing and other practices can withstand scrutiny of newly heightened fraud investigations and review. Prospective new providers and certain ownership change transactions are blocked during the moratorium period.

BACKGROUND

On May 13, 2026, the Centers for Medicare & Medicaid Services (CMS) published two Federal Register notices imposing immediate, nationwide, six-month enrollment moratoria on new Medicare enrollment for hospice providers and home health agencies (HHAs). The moratoria are effective as of the May 13, 2026 publication date and apply to all states, territories, and the District of Columbia. This action follows an earlier, still-active moratorium on durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) companies imposed in February 2026, making these among the most expansive fraud-prevention actions in CMS’ history.

At the same time, CMS issued preliminary guidance to states regarding new payment limits on Medicaid State Directed Payments (SDPs) under managed care, pursuant to the recently enacted “One Big Beautiful Bill Act.”

NATIONWIDE MEDICARE ENROLLMENT MORATORIA: HOSPICES AND HOME HEALTH AGENCIES

Legal Authority

CMS derives its moratorium authority from Section 1866(j)(7) of the Social Security Act, added by the Affordable Care Act, and implemented through 42 C.F.R. § 424.570. CMS may impose a temporary moratorium on new Medicare, Medicaid, or CHIP enrollment when it determines there is a significant potential for fraud, waste, or abuse. The decision to impose a moratorium is not subject to judicial review.

Scope and Effective Date

Both moratoria became effective May 13, 2026 and will remain in effect for six months, subject to renewal in additional six-month increments. CMS will publish any extension or termination in the Federal Register. The moratoria cover:

  • All new initial Medicare enrollment applications for hospice providers and HHAs (including HHA branch offices)
  • Certain changes in majority ownership (CIMOs) that would require initial re-enrollment—a mechanism CMS has identified as frequently exploited to obscure bad-actor control

The moratoria do NOT affect:

  • Currently enrolled hospice providers and HHAs, which may continue providing services and billing Medicare without interruption;
  • Changes in practice location (unless relocating from outside to inside the moratorium area);
  • Routine administrative changes (phone number, address, etc.);
  • Any enrollment application received by a Medicare contractor before May 13, 2026

Rationale: Data-Driven Findings

CMS grounded both moratoria in extensive data analysis and law enforcement experience. Key findings cited by the agency include:

  • In Los Angeles County alone, the number of enrolled HHAs rose more than 40 percent between 2019 and 2023, with over 1,000 new HHAs enrolling despite no corresponding change in the Medicare beneficiary population. Los Angeles County now holds roughly 12–15 percent of all HHAs nationwide, while accounting for only approximately 3 percent of the national Medicare beneficiary community.
  • Clusters of multiple HHAs operating from a single shared address have been detected in Ohio, Texas, Michigan, North Carolina, and Nevada, which CMS views as a strong indicator of fraud.
  • CMS, in coordination with Vice President JD Vance’s Anti-Fraud Task Force, has suspended payments to approximately 800 hospices and HHAs in Los Angeles, which were responsible for $1.4 billion in Medicare spending in the prior year, with $70 million in payments suspended to date.
  • Numerous recent criminal convictions and civil settlements involve hospice and HHA operators across many states, including multimillion-dollar fraud schemes in Massachusetts, Michigan, Texas, Ohio, Illinois, Oklahoma, and Pennsylvania.

CMS emphasized that because fraud schemes are “highly migratory,” a nationwide moratorium—rather than a targeted geographic one—is necessary to prevent bad actors from simply relocating to avoid scrutiny.

Applicability to Medicaid and CHIP

The moratoria announced in the Federal Register apply to Medicare enrollment only. CMS has expressly invited each state to consult with the agency about implementing a parallel moratorium tailored to their Medicaid and CHIP programs. States are not required to comply if they determine that doing so would adversely affect beneficiary access to care.

Accompanying Enforcement Intensification

CMS also announced that, during the moratorium period, it will:

  • Intensify targeted investigations and deploy advanced data analytics;
  • Accelerate revocation and deactivation of currently enrolled providers suspected of fraud;
  • Continue nationwide site visits to hospices to verify operations;
  • Maintain heightened oversight of newly enrolled hospice providers in states identified as high-risk: Arizona, California, Georgia, Ohio, Nevada, and Texas;
  • Operate a new publicly available hospice scoring system to increase transparency;
  • Implement enhanced HHA enrollment screening, including site verification and fingerprinting-based background checks; and
  • Expand a pre- and post-claim review demonstration for HHA claims in Florida, Illinois, Oklahoma, Ohio, North Carolina, and Texas.

Existing hospice and home health providers and those in the targeted regions particularly are urged to work with qualified legal counsel within the scope of attorney-client privilege to assess and tighten their existing practices and audit prior billings in response to recent OIG and other recent reports to assess and address risks from practices the government now views as fraudulent or aggressive as this enhanced scrutiny targets identification of practices the government views as fraud and other aggressive practices by current providers. Providers subjected to this scrutiny must be prepared to defend their actions to avoid fraud charges, recoupment, program participation suspensions or exclusions or other adverse consequences.

Moratorium Termination

Under 42 C.F.R. § 424.570(d), CMS may lift a moratorium early if: (1) a Presidential disaster declaration applies; (2) circumstances warranting the moratorium have abated; (3) a public health emergency is declared; or (4) the Secretary determines the moratorium is no longer necessary. Upon lifting, formerly blocked provider types would be assigned to the “high” screening level for six months.

Appeals

A provider whose enrollment application is denied due to the moratorium may appeal under 42 C.F.R. part 498. However, the scope of such an appeal is limited solely to whether the moratorium applies to the particular provider—not to the merits of CMS’ decision to impose the moratorium. Application fees will be refunded where a denial results from the moratorium.

CMS GUIDANCE ON MEDICAID STATE DIRECTED PAYMENT LIMITS

Overview

On September 9, 2025, CMS issued preliminary guidance to states implementing new federal payment limits on Medicaid State Directed Payments (SDPs) in managed care, as required by the One Big Beautiful Bill Act. SDPs—arrangements that direct how Medicaid managed care plans pay providers—have grown dramatically, from use by only two states in 2016 to 39 states today, with projected annual SDP spending exceeding $124.3 billion for FY 2025 and $144.6 billion for FY 2026.

New Payment Limits

Effective for rating periods beginning on or after July 4, 2025, SDPs for the following service categories must not exceed specified Medicare rate benchmarks:

  • Inpatient hospital services;
  • Outpatient hospital services;
  • Nursing facility services; and
  • Qualified practitioner services at an academic medical center.

The applicable ceiling is:

  • 100% of the Medicare rate in Medicaid expansion states;
  • 110% of the Medicare rate in non-expansion states; or
  • Where no Medicare rate exists, the Medicaid state plan rate applies.

Grandfathering

Certain SDPs submitted or approved before July 4, 2025 may qualify for a temporary grandfather period through rating periods beginning January 1, 2028, followed by a phased reduction to meet the new limits. CMS will notify states in approval letters whether a particular SDP likely qualifies for grandfathering.

Next Steps for States

States must revise any pending or future SDP preprints that do not qualify for grandfathering before CMS will continue review. Health care providers participating in SDPs should coordinate with their state Medicaid agencies to understand the impact of these limits on their payment arrangements.

IMPLICATIONS FOR PROVIDERS

Hospice and home health providers should assess the following in light of these actions:

For Currently Enrolled Providers

For currently enrolled providers:

  • Operations may continue uninterrupted. No action is required to maintain current enrollment status. However, currently enrolled providers must ensure that current and future practices can withstand the heightened oversight and scrutiny HHS and it’s auditors will apply to current and previously submitted bills as part of their fraud investigation and enforcement practices.
  • Expect heightened CMS scrutiny during the moratorium period, including potential site visits, billing audits, and enhanced data monitoring.
  • Providers in the identified high-risk states (AZ, CA, GA, NV, OH, TX for hospices) should anticipate heightened oversight and ensure documentation and compliance programs are robust.
  • Providers in the HHA pre- and post-claim review demonstration states (FL, IL, OK, OH, NC, TX) should review their claims processes for compliance.

For Providers Seeking New Enrollment

For providers seeking new enrollment:

  • Applications received by a Medicare contractor before May 13, 2026 will be processed. Providers should confirm their contractor’s receipt of a timely-filed application.
  • Applications submitted on or after May 13, 2026 will be denied. Application fees will be refunded in these instances.
  • Any denied applicant wishing to contest applicability of the moratorium may appeal under 42 C.F.R. part 498, with the narrow scope described above.
  • Any provider granted authorization to operate under the programs must be prepared to meticulously comply with the current rules, taking to count all guidance passed and emerging.

For Transactions Involving Ownership Changes

For transactions involving ownership changes:

  • Parties to acquisitions, mergers, or other transactions involving hospice or HHA ownership should carefully evaluate whether the transaction constitutes a “change in majority ownership” (CIMO) that would require initial re-enrollment under 42 C.F.R. § 424.550.
  • CIMOs within 36 months of an HHA’s initial enrollment (or most recent prior CIMO) that trigger initial re-enrollment will be blocked during the moratorium. Deal teams should factor this into transaction planning and timelines.

For Organizations Participating in Medicaid Managed Care SDPs

Organizations participating in Medicaid Managed Care SDPs should:

  • Review existing and planned SDP arrangements for compliance with the new Medicare rate caps.
  • Identify whether any current SDPs qualify for the grandfathering period and assess the financial impact of the eventual phase-down.
  • Work with state Medicaid agency partners to ensure pending preprints are revised as necessary.

Patients and Their Caregivers

Patients and their caregivers should anticipate and prepare to cope with likely delays and disruptions in the ability to access care and changes in services as providers respond to the moratorium, rule changes and enforcement. Declines in staffing and services also are likely due to rule changes and reimbursement cuts.

For Help or More Information

The author of this update, Cynthia Marcotte Stamer advises hospices, home health agencies, and other Medicare and Medicaid providers and other health industry clients on enrollment matters, compliance programs, government investigations, transaction due diligence, reimbursement compliance and disputes, audits and investigations, and other legal and operational compliance and risk management and legislative and regulatory affairs. She is available to assist your organization in assessing the impact of these developments and navigating the compliance and strategic steps that follow. For more information about these  or other health care, managed care and other health benefits, or other health care developments, please contact Ms. Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.

About the Author

Peer recognized as “Top Rated Lawyer” and “LEGAL LEADER™ “Top Rated Lawyer” and “Best Lawyer” for her work in Health Care Law, Labor and Employment Law; ERISA & Employee Benefits,” and “Business and Commercial Law,” Cynthia Marcotte Stamer is an A Martindale-Hubble “AV-Preeminent” (Top 1%) attorneys board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for her more than 35 years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications including leading edge work on PBM, pharmacy and pharmaceutical and other health care, managed care, insurance, and insured and self-insured contracting, design, administration and regulation.. 

Author of numerous highly regarded works on health care fraud and other compliance, risk management and operations,  Chair of the Tort Trial and Insurance Practice Section Medicine and Law Committee, past Chair of the ABA Health Law Section Managed Care & Insurance Interest Group, the ABA International Section Life Sciences Committee and the former Group Chair and Welfare Benefit Committee Co-Chair of the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health industry legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her career has focused heavily on working with hospitals, health care systems, long term care, rehabilitation, home health, hospice, clinics, and other health care organizations; physician and other provider organizations and practitioners; accreditation, medical staff, peer review, and quality committees and organizations; billing, audit, practice management, utilization management, EMR, claims, payroll and other technology, billing and reimbursement and other services and product vendors and services organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; DME; health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations; consultants; products and solutions consultants and developers; investors; managed care organizations, self-insured health and other employee benefit plans, their sponsors, fiduciaries, administrators and service providers, insurers and other payers, health industry advocacy and other service providers and groups and other health and managed care industry clients as well as federal and state legislative, regulatory, investigatory and enforcement bodies and agencies on billing and reimbursement, government investigations and enforcement, and other legal and operational compliance and risk management, performance and workforce management, regulatory and public policy, and other legal and operational concerns. 

Author of a multitude of highly regarded publications and presentations,  Ms. Stamer is widely recognized for her thought leadership on these and other health care, managed care and other health plan,and other health industry matters.  In addition, Ms. Stamer contributes her time and leadership to numerous policy, professional, civil and other organizations including service as the, the American Bar Association (ABA) International Section Life Sciences Committee Vice Chair, a Scribe for the ABA Joint Committee on Employee Benefits (JCEB) Annual OCR Agency Meeting and a former Council Representative, Past Chair of the ABA Managed Care & Insurance Interest Group, former Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, and a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her extensive publications and thought leadership as well as leadership involvement in a broad range of other professional and civic organizations. For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources. 

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general information and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation considering the specific facts and circumstances presented in their unique circumstance at the particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author reserves the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law constantly and often rapidly evolves, subsequent developments that could impact the currency and completeness of this discussion are likely. The author and Solutions Law Press, Inc. disclaim and have no responsibility to provide any update or otherwise notify anyone of any  fact or law specific nuance, change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2026 Cynthia Marcotte Stamer. Non-exclusive right to republish granted to Solutions Law Press, Inc.™ For information about republication, please contact the author directly. All other rights reserved.

Leave a Comment » | Conditions of Participation, Corporate Compliance, Doctor, Evidence Based Medicine, Government contractor, Health Care, Health care coding, Health Care Finance, Health Care Fraud, Health Care Provider, Health Care Quality, health care reimbursement, healthcare, HHS, home health, Hospice, hospitals, Inpatient Rehabilitation, Inpatient Rehabilitation Facility, long-term care, Medicaid, Medicaid Advantage, Medicaid Advantage, Medicare, Medicare Advantage, Medicare Advantage, Medicare Fee Schedule, Mergers and Acquisitions, Money Laundering, nursing home, participating provider, Reimbursement | Tagged: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , | Permalink
Posted by Cynthia Marcotte Stamer

Best Physician Practices to Reduce Liability in Telemedicine Care

May 8, 2026

With telemedicine enjoying increased popularity among physicians and many patients and eligibility for coverage by payers, many physicians and other providers are expanding their telemedicine services. While proper telemedicine care often benefits patients, providers and payers, physicians must recognize and manage the distinct liability risks telemedicine care can create for physicians, especially around diagnosis, privacy, documentation, billing, and fragmented follow-up. Telemedicine: dos and don’ts to mitigate liability risk; Telehealth and Patient Safety.

1. Know when telemedicine is appropriate

The biggest liability trap in telemedicine is using it for patients or conditions that require hands-on examination, urgent testing, or immediate procedural intervention. Telehealth and Patient Safety; Malpractice Risks with Telehealth: The Do’s and Don’ts. Physicians should maintain clear protocols that identify red flags, define which complaints are unsuitable for virtual-only care, and require prompt in-person referral when the virtual exam is inadequate for safe decision-making. Telehealth and Patient Safety; Telemedicine: dos and don’ts to mitigate liability risk.

2. Document the virtual encounter like it will be reviewed later

Risk management literature stresses that information gathered during a telemedicine visit should be preserved in the medical record to meet the standard of care. Telemedicine: dos and don’ts to mitigate liability risk. Documentation should note patient identity verification, location, consent to telemedicine, who else was present, technical limitations, history obtained, elements of the virtual exam, clinical reasoning, and why virtual management was or was not appropriate. (Telehealth Privacy Tips for Providers; Telemedicine: dos and don’ts to mitigate liability risk)

3. Make privacy and security part of the workflow

Federal guidance for providers recommends confirming the identities of everyone present at each telehealth session, using password-protected systems, creating unique user identifications, and routinely reviewing telehealth privacy and security settings. Telehealth Privacy Tips for Providers. HHS also states that providers have an ethical obligation to discuss privacy and security risks with patients and to stay current on legal requirements for HIPAA compliance. Telehealth Privacy Tips for Providers; HHS resources for providers about telehealth privacy and security.

4. Reduce misdiagnosis risk during the virtual exam

The Agency for Healthcare Research and Quality (AHRQ) identifies several contributors to diagnostic error in telehealth, including limited physical examination, poor communication, and reliance on patients or family members to collect or describe findings. Telehealth and Patient Safety. Practical safeguards include using structured telehealth exam techniques, asking patients to demonstrate symptoms or functional limitations on camera when appropriate, involving a family member or advocate if needed, and scheduling in-person follow-up whenever the diagnosis remains uncertain. Malpractice Risks with Telehealth: The Do’s and Don’ts; AHRQ Safety Program for Telemedicine.

5. Protect continuity of care

Telemedicine liability increases when care is fragmented and the treating physician lacks access to the broader clinical picture. Telehealth and Patient Safety; Performance Measures for Physicians Providing Clinical Care Using Telemedicine: A Position Paper From the American College of Physicians. Physicians should integrate telemedicine visits into the same record and follow-up system used for office care, communicate results and next steps clearly, and avoid isolated transactional encounters that lack accountability for ongoing management. Telehealth and Patient Safety; Performance Measures for Physicians Providing Clinical Care Using Telemedicine: A Position Paper From the American College of Physicians.

6. Use extra caution with prescribing

Prescribing decisions made through telemedicine can carry elevated risk when the diagnosis is uncertain, the patient relationship is thin, or the medication has significant abuse potential. Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities; Special Registrations for Telemedicine and Limited State Telemedicine Registrations. Physicians should verify identity, review available prescription drug monitoring data where required, document medical necessity carefully, and use a lower threshold for in-person evaluation before prescribing controlled substances or escalating therapy. DEA and HHS Issue Final Telemedicine Rule for Buprenorphine Access; Telehealth Privacy Tips for Providers.

7. Train the practice, not just the physician

AHRQ’s telemedicine safety work shows that safer virtual care depends on practice-level workflows, education, and continuous review rather than individual clinical judgment alone. AHRQ Safety Program for Telemedicine; AHRQ Safety Program for Telemedicine. Staff should be trained on intake, privacy checks, escalation protocols, informed consent, patient instructions, and what to do when technology fails during a clinically significant encounter.AHRQ Safety Program for Telemedicine; Telehealth Privacy Tips for Providers.

8. Confirm malpractice insurance coverage and regulatory compliance

Liability management also includes confirming that malpractice coverage extends to telemedicine services and that the practice complies with applicable licensing, privacy, and prescribing rules. Source 110; Telehealth Privacy Tips for Providers. This is especially important for cross-border care, platform-based practice models, and remote prescribing arrangements that can create added regulatory exposure, particularly as prescribers generally simultaneously must comply with licensing, regulatory and ethical requirements in both the location of the prescriber, the patient, and where the telemedicine corporation is incorporated and otherwise has sufficient contacts to be subject to state regulation. Source 110; Special Registrations for Telemedicine and Limited State Telemedicine Registrations.

9. Follow applicable Medicare or other applicable Public or private plan provider billing and documentation requirements

Physician and other telemedicine providers also should carefully follow coverage and documentation requirements of the Meficare or other coverage of the patient to avoid coverage denials and mitigate fraudulent billing risks.
Physicians also need to remember that telemedicine compliance is not uniform across payers. Medicare operates under a detailed federal framework that defines covered telehealth services, places conditions on audio-only billing, and has drawn recent Department of Health and Human Services (HHS) Office of Inspector General (OIG) scrutiny over coding and improper payments. What to Know About Medicare Coverage of Telehealth; Medicare payment policies; CMS Could Strengthen Medicare Program Safeguards To Prevent and Detect Potentially Improper Payments for Virtual Care Services) Private payer rules are often driven by state parity statutes and insurer-specific policies, which can differ on payment parity, audio-only coverage, documentation standards, and utilization controls. Requirements for Private Payer Telehealth Reimbursement; Audio-Only Telehealth Post-PHE – Medicare, Medicaid, and Private Payers.

Physicians should know that the Centers for Medicare and Medicaid Services (CMS) and the OIG are scrutinizing Medicare telemedicine billing more closely, which raises liability and compliance risk even when the underlying care is clinically appropriate.

In April 2026, OIG reported that CMS made about $1.96 million in potential revenue improper payments for 173,287 virtual check-in services and about $298,200 in potential improper payments for 10,237 e-visit services, and recommended stronger system edits, clearer code descriptions, and more provider education. CMS Could Strengthen Medicare Program Safeguards To Prevent and Detect Potentially Improper Payments for Virtual Care Services.

The OIG report found that CMS could save millions by strengthening safeguards against improper payments for virtual check-ins and e-visits. The audit identified over $2.26 million in potentially improper payments from 2019 to 2022, primarily due to lack of system edits for services bundled with other care. CMS Could Strengthen Medicare Program Safeguards To Prevent and Detect Potentially Improper Payments for Virtual Check-in and E-visit Services. The OIG report’s recommends CMS tighten requirements and system and audit controls to detect and redress improper telemedicine billing and reimbursement practices including:

Past program-integrity work on Medicare telehealth services also identified billing patterns that can trigger further scrutiny, including billing both a telehealth service and a facility fee for most visits and patterns suggestive of duplicate or otherwise inappropriate claims. Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks.

  • Improper Virtual Check-ins: Approximately $1.96 million in payments occurred for virtual check-ins that took place within 7 days after or 24 hours before a related Evaluation and Management service, violating Medicare rules.
  • Duplicative E-Visits: Around $298,200 in payments were for e-visits provided within 7 days of another e-visit for the same patient and diagnosis.
  • System Limitations: CMS and Medicare Administrative Contractors (MACs) lacked automated system edits to detect these related, closely timed services. 

For physicians, the practical lesson is that telemedicine documentation, modifier use, code selection, supervision rules, and internal billing audits should be treated as core risk-management functions rather than back-office details. As a result, risk management should include payer-specific billing protocols rather than assuming one telemedicine workflow satisfies Medicare and commercial plan requirements alike. Physicians and other telemedicine providers that serviced Medicare or Medicaid patients also should consider conducting attorney-client privileged audits of previously billed care to assess exposures to potential CMS and its auditor’s scrutiny expected in response to OIG’s recommendations.

10. Manage FTC and deceptive advertising risk

Telemedicine liability is not limited to malpractice. Marketing claims can also create regulatory exposure under Section 5 of the FTC Act when ads misstate price, expected outcomes, consumer reviews, cancellation terms, or the nature of clinician access. (FTC Takes Action Against Telemedicine Firm NextMed; Health Products Compliance Guidance) In 2025, the FTC took action against telemedicine company NextMed alleging misleading prices, fake reviews, deceptive before-and-after images, and unsubstantiated average weight-loss claims used to sell GLP-1-related programs. FTC Takes Action Against Telemedicine Firm NextMed; FTC Approves Final Order against Telehealth Provider NextMed.

Deceptive or misleading marketing, communications or actions also can create informed consent and other disciplinary and malpractice risks.

For physicians and telemedicine practices, the safest rule is that promotional statements should match the actual patient experience and be supportable with competent evidence. Federal Trade Commission; Health Products Compliance Guidance.

Risk-management steps include reviewing websites and social ads for hidden fees, avoiding guarantees or typical-results claims without substantiation, ensuring testimonials come from real patients with required disclosures, preserving records supporting objective claims, and aligning cancellation, refund, and auto-renewal terms with what is clearly disclosed to consumers.

Practical takeaways

The safest approach is not to treat virtual care as identical to in-person care in every setting, but to use telemedicine with clear workflows, strong documentation, and low thresholds for escalation to in-person evaluation when clinical uncertainty is high. Performance Measures for Physicians Providing Clinical Care Using Telemedicine: A Position Paper From the American College of Physicians; Malpractice Risks with Telehealth: The Do’s and Don’ts.

For most physicians, the best liability strategy is simple: use telemedicine where it adds value, document carefully, protect privacy, keep care connected, ensure fulfillment of applicable payer requirements before naming coverage claims, and convert to in-person care quickly when the virtual format leaves too much uncertainty. Telemedicine: dos and don’ts to mitigate liability risk; Telehealth and Patient Safety; Telehealth Privacy Tips for Providers.

Want more information? The author of this article, Cynthia Marcotte Stamer has worked extensively on telemedicine and other health care legal and operational risk management and compliance for more than 30 years. If you have questions about this or other health care concerns, contact the author. 

For More Information

We hope this update is helpful. For more information about the  or other health or other employee benefits, human resources, or health care developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.

Solutions Law Press, Inc. invites you receive future updates by registering on our Solutions Law Press, Inc. Website and participating and contributing to the discussions in our Solutions Law Press, Inc. LinkedIn SLP Health Care Risk Management & Operations Group, HR & Benefits Update Compliance Group, and/or Coalition for Responsible Health Care Policy.

About the Author

Peer recognized as “Top Rated Lawyer” and “LEGAL LEADER™ “Top Rated Lawyer” and “Best Lawyer” for her work in Health Care Law, Labor and Employment Law; ERISA & Employee Benefits,” and “Business and Commercial Law,” Cynthia Marcotte Stamer is an A Martindale-Hubble “AV-Preeminent” (Top 1%) attorneys board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for her more than 35 years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications including leading edge work on telemedicine, PBM, pharmacy and pharmaceutical and other health care, managed care, insurance, and insured and self-insured contracting, design, administration and regulation.. 

Author of numerous highly regarded works on telemedicine and other health care practices and concerns,  current American Bar Association (ABA) Tort Trial and Insurance Practice Section Medicine and Law Committee, past Chair of the ABA International Section Life Sciences Committee and the ABA Health Law Section Managed Care & Insurance Interest Group, and past Group Chair and current Welfare Benefit Committee Co-Chair of the ABA RPTE Employee Benefits & Other Compensation Group, Ms. Stamer is widely recognized for her decades of pragmatic, leading edge work, scholarship and thought leadership on health and other privacy and data security and other health industry legal, public policy and operational concerns. 

Ms. Stamer’s work throughout her career has focused heavily on working with health care providers and organizations; managed care, health and other employee benefit plan, and insurance programs; health, Human Resources and other data abd technology; and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns.  As a part of this work, she has continuously and extensively worked with domestic and international health plans, their sponsors, fiduciaries, administrators, and insurers; managed care and insurance organizations; third party administrators and other health benefit service providers; hospitals, health care systems, physicians and other health care providers, accreditation, peer review and quality committees and organizations; billing, utilization management, management services organizations, group purchasing organizations; pharmaceutical, pharmacy, and prescription benefit management and organizations; consultants; investors; EMR, claims, payroll and other technology, billing and reimbursement and other services and product vendors; products and solutions consultants and developers; investors; managed care organizations, self-insured health and other employee benefit plans, their sponsors, fiduciaries, administrators and service providers, insurers and other payers, health industry advocacy and other service providers and groups and other health and managed care industry clients as well as federal and state legislative, regulatory, investigatory and enforcement bodies and agencies.

She also has extensive experience helping health care systems and organizations, group and individual health care providers, health plans and insurers, health IT, life sciences and other health industry clients prevent, investigate, manage and resolve  sexual assault, abuse, harassment and other organizational, provider and employee misconduct and other performance and behavior; manage Section 1557, Civil Rights Act and other discrimination and accommodation, and other regulatory, contractual and other compliance; vendors and suppliers; contracting and other terms of participation, medical billing, reimbursement, claims administration and coordination, Medicare, Medicaid, CHIP, Medicare/Medicaid Advantage, ERISA and other payers and other provider-payer relations, contracting, compliance and enforcement; Form 990 and other nonprofit and tax-exemption; fundraising, investors, joint venture, and other business partners; quality and other performance measurement, management, discipline and reporting; physician and other workforce recruiting, performance management, peer review and other investigations and discipline, wage and hour, payroll, gain-sharing and other pay-for performance and other compensation, training, outsourcing and other human resources and workforce matters; board, medical staff and other governance; strategic planning, process and quality improvement; meaningful use, EMR, HIPAA and other technology,  data security and breach and other health IT and data; STARK, ant kickback, insurance, and other fraud prevention, investigation, defense and enforcement; audits, investigations, and enforcement actions; trade secrets and other intellectual property; crisis preparedness and response; internal, government and third-party licensure, credentialing, accreditation, HCQIA and other peer review and quality reporting, audits, investigations, enforcement and defense; patient relations and care;  internal controls and regulatory compliance; payer-provider, provider-provider, vendor, patient, governmental and community relations; facilities, practice, products and other sales, mergers, acquisitions and other business and commercial transactions; government procurement and contracting; grants; tax-exemption and not-for-profit; privacy and data security; training; risk and change management; regulatory affairs and public policy; process, product and service improvement, development and innovation, and other legal and operational compliance and risk management, government and regulatory affairs and operations concerns. to establish, administer and defend workforce and staffing, quality, and other compliance, risk management and operational practices, policies and actions; comply with requirements; investigate and respond to Board of Medicine, Health, Nursing, Pharmacy, Chiropractic, and other licensing agencies, Department of Aging & Disability, FDA, Drug Enforcement Agency, OCR Privacy and Civil Rights, Department of Labor, IRS, HHS, DOD, FTC, SEC, CDC and other public health, Department of Justice and state attorneys’ general and other federal and state agencies; JCHO and other accreditation and quality organizations; private litigation and other federal and state health care industry actions: regulatory and public policy advocacy; training and discipline; enforcement;  and other strategic and operational concerns.

Author of a multitude of highly regarded publications and presentations,  Ms. Stamer is widely recognized for her thought leadership on these and other health care, managed care and other health plan,and other health industry matters.  In addition, Ms. Stamer contributes her time and leadership to numerous policy, professional, civil and other organizations including service as the, the American Bar Association (ABA) International Section Life Sciences Committee Vice Chair, a Scribe for the ABA Joint Committee on Employee Benefits (JCEB) Annual OCR Agency Meeting and a former Council Representative, Past Chair of the ABA Managed Care & Insurance Interest Group, former Vice President and Executive Director of the North Texas Health Care Compliance Professionals Association, past Board President of Richardson Development Center (now Warren Center) for Children Early Childhood Intervention Agency, past North Texas United Way Long Range Planning Committee Member, and past Board Member and Compliance Chair of the National Kidney Foundation of North Texas, and a Fellow in the American College of Employee Benefit Counsel, the American Bar Foundation and the Texas Bar Foundation, Ms. Stamer also shares her extensive publications and thought leadership as well as leadership involvement in a broad range of other professional and civic organizations. For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.

About Solutions Law Press, Inc.™

Solutions Law Press, Inc.™ provides human resources and employee benefit and other business risk management, legal compliance, management effectiveness and other coaching, tools and other resources, training and education on leadership, governance, human resources, employee benefits, data security and privacy, insurance, health care and other key compliance, risk management, internal controls and operational concerns. If you find this of interest, you also be interested reviewing some of our other Solutions Law Press, Inc.™ resources. 

If you or someone else you know would like to receive future updates about developments on these and other concerns, please be sure that we have your current contact information including your preferred e-mail by creating your profile here.

NOTICE: These statements and materials are for general information and purposes only. They do not establish an attorney-client relationship, are not legal advice or an offer or commitment to provide legal advice, and do not serve as a substitute for legal advice. Readers are urged to engage competent legal counsel for consultation and representation considering the specific facts and circumstances presented in their unique circumstance at the particular time. No comment or statement in this publication is to be construed as legal advice or an admission. The author reserves the right to qualify or retract any of these statements at any time. Likewise, the content is not tailored to any particular situation and does not necessarily address all relevant issues. Because the law constantly and often rapidly evolves, subsequent developments that could impact the currency and completeness of this discussion are likely. The author and Solutions Law Press, Inc. disclaim and have no responsibility to provide any update or otherwise notify anyone of any  fact or law specific nuance, change, limitation, or other condition that might affect the suitability of reliance upon these materials or information otherwise conveyed in connection with this program. Readers may not rely upon, are solely responsible for, and assume the risk and all liabilities resulting from their use of this publication.

Circular 230 Compliance. The following disclaimer is included to ensure that we comply with U.S. Treasury Department Regulations. Any statements contained herein are not intended or written by the writer to be used, and nothing contained herein can be used by you or any other person, for the purpose of (1) avoiding penalties that may be imposed under federal tax law, or (2) promoting, marketing or recommending to another party any tax-related transaction or matter addressed herein.

©2026 Cynthia Marcotte Stamer. Non-exclusive right to republish granted to Solutions Law Press, Inc.™ For information about republication, please contact the author directly. All other rights reserved.

Leave a Comment » | Health Care, Health Care Provider, Health Care Quality, Health IT, home health, Hospital, Medicaid, Medicaid Advantage, Medical Licensure, Medical Malpractice, Medicare, Medicare Advantage, Medicare Fee Schedule, Physician, Physician Licensing, Prescription Drugs, Reimbursement, Telemedicine | Tagged: , , , , , , , , , , , , , , , , , , , , , , , , | Permalink
Posted by Cynthia Marcotte Stamer