CMS Talks Doc Pay Policies, Prior Auth, and Fraud/Waste/Abuse
All the non-quality news from the 2026 CMS Quality Conference.
On March 16-17, the Centers for Medicare and Medicaid Services (CMS) held its 2026 Quality Conference (QualCon). This annual event featured enhanced production values and concluded with a session led by life coach to the stars, Tony Robbins. This was definitely not your father’s QualCon (extra points if you catch my Oldsmobile reference!).
While quality issues and promotion of Make America Healthy Again (MAHA) took center stage, there was still significant non-quality news that emerged from this meeting. Some key takeaways.
Artificial Intelligence (AI): Each session emphasized the growing and important role AI plays at CMS. Staff is utilizing AI to enhance their backend workflows, and AI is increasingly used on the frontend for initiatives impacting physicians and beneficiaries.
Over the next 2-3 years, CMS will be busy: Political leaders acknowledged that they have set ambitious goals for the agency within the remaining time of this current administration. They said they plan to be very busy and hope to accomplish a lot. Leadership is looking beyond regulations, which can be time-consuming, to implement change. Rather, they are focusing on the agency’s power to convene. Insurers’ voluntary pledge to “fix” the broken prior authorization system was cited as an example of how convening can accelerate change.
Changes to the Medicare Physician Fee Schedule (PFS) will continue: Leadership proudly discussed the significant updates they made to the 2026 Medicare PFS, including increasing the use of outside data to implement the 2.5% work RVU cut to non-time-based CPT codes (also called the efficiency adjustment) and other adjustments that enhanced primary care payments and they stated provided more accurate payments overall.
Reimagining Prior Authorization: The agency aims to “fix” prior authorization, which it views as a guardrail against low-value care. They are examining prior authorization in both Original Medicare and Medicare Advantage (MA). In Original Medicare, they plan to learn from the Wasteful and Inappropriate Service Reduction (WISeR) Model, a six-year AI-driven prior authorization initiative launched on January 1 that affects six states and 13 services. The insights gained from this model could be applied to other states or medical services. For MA, they have launched a voluntary pilot with several plans and are collecting data on prior authorization within the MA environment.
Fraud, waste, and abuse efforts continue to grow: As we often hear, this remains a top priority for the administration. During a session hosted by the Office of Program Integrity, it was noted that they have established a war room that meets at least twice a week, and Dr. Oz is actively posting many videos about their work on social media. On a substantive note, the agency has shifted from chasing dollars already paid out to preventing improper payments before they happen. Following their crackdown on fraud involving skin substitutes, which is expected to save CMS billions of dollars, the agency is now focusing on esketamine nasal spray, prescribed for severe depression. The increased use and variation at the state level have raised concerns at CMS. They are also targeting fraud in hospice care. The agency plans to release a new rule and several notices related to other fraud, waste, and abuse initiatives in the coming months.
CMS is hiring. During several sessions, leadership mentioned that CMS was hiring and encouraged conference attendees to explore opportunities with the agency. As you may recall, earlier in the Trump Administration, mass firings occurred at CMS and throughout the federal government.
More information on the 2026 QualCon is available HERE.
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For more information and questions, please contact:
Sheila Madhani
Madhani Healthcare Consulting
Email: smadhani@madhani-health.com
Tel: (202) 679-2977