$56.5M settlement over false Medicare Advantage diagnoses; no safe level of drinking; AMA calls for Medicaid work requirement exemptions – Morning Medical Update

$56.5M settlement over false Medicare Advantage diagnoses

Three entities tied to in-home health assessments will pay tens of millions after allegedly inflating diagnosis codes to boost Medicare payments.

Matrix Medical Network, HealthFair and HealthFair founder Shahriah "James" Ekbatani have agreed to pay $56.5 million to settle False Claims Act allegations that they submitted invalid diagnosis codes to the Medicare Advantage program to inflate risk-adjustment payments from the Centers for Medicare & Medicaid Services (CMS). Matrix, headquartered in Nashville, Tennessee, will pay $36.5 million; HealthFair will pay $5 million; and Ekbatani will pay $15 million.

The government alleged that from 2014 to 2019, Matrix's in-home assessments generated false diagnoses of conditions including atrial fibrillation, rheumatoid arthritis and COPD that were unsupported by clinical criteria or any other treating provider. HealthFair, acquired by Matrix in 2018, was separately accused of recording diagnoses — including HIV/AIDS and metastatic cancer — without documentation confirming the conditions existed. Both cases were brought under the FCA's whistleblower provisions; the two relators will receive a combined $10.9 million.

Shelved alcohol study finds no safe level of drinking

The federally commissioned research the Trump administration declined to use for dietary guidelines is now public.

A federally commissioned study on alcohol and health risks, which was sidelined by the Trump administration before this year's dietary guidelines were finalized, was published Tuesday in the Journal of Studies on Alcohol and Drugs. The study found no protective effect of alcohol at any consumption level.

Males consuming 14 drinks per week — the upper limit under the previous dietary guidelines — face a lifetime risk of dying from an alcohol-related cause of 1 in 25. The Trump administration opted not to incorporate the findings into updated dietary guidelines, relying instead on a separate National Academies study, and issued guidance advising Americans to drink "less" without specifying quantities. The study's authors argue the findings support capping daily consumption at one drink.

"Giving people quantity information is necessary to make a truly informative guideline," said Timothy Naimi, M.D., one of the study's authors. An HHS official said Tuesday’s study was not reviewed by federal officials and had key differences to the federally commissioned work.

American Medical Association calls for broader Medicaid work requirement exemptions

The new policy pushes back on what the AMA calls a too-narrow federal definition of medical frailty.

Physicians at the American Medical Association’s (AMA's) 2026 Annual Meeting adopted new policy urging federal and state policymakers to ensure Medicaid work requirements include automatic exemptions for patients with serious illnesses and their caregivers. On June 1, CMS issued an updated rule on work requirements, which the AMA says defines medical frailty too narrowly, putting patients with complex chronic conditions at risk of losing coverage.

The AMA will advocate for exemptions covering patients with life-threatening or complex chronic conditions, functional impairments or ongoing care needs, and will push CMS and state Medicaid agencies to minimize paperwork burdens on both patients and physicians.

"Patients undergoing cancer treatment, living with advanced heart disease, managing severe mental illness, recovering from major medical events, or coping with other complex conditions should not risk losing coverage because of narrow interpretations of medical frailty or excessive paperwork requirements," said Melissa J. Garretson, M.D., a member of the AMA Board of Trustees.