AHA pushes CMS for targeted fraud oversight

The American Hospital Association (AHA) submitted a March 30, 2026 comment letter to CMS in response to the agency’s CRUSH request for information on regulations aimed at uncovering suspicious healthcare activity and reducing fraud, waste, and abuse.

What happened

In the letter, AHA said it supports efforts to hold bad actors accountable in federal healthcare programs, but warned that hospitals already face heavy compliance obligations and should not be hit with added rules that create more administrative burden without clear evidence they will help. AHA pointed to the cost of compliance for hospitals and urged the Centers for Medicare & Medicaid Services (CMS) to make any new fraud-related changes data-driven and targeted.

A major part of the response focused on Medicare Advantage, where AHA argued that some insurer practices deserve closer scrutiny, including difficult prior authorization requirements, unclear coverage rules, narrow or changing networks, restrictive medical necessity criteria, and the effects of vertical integration. AHA also told CMS to strengthen and better use its existing oversight tools in Medicaid and CHIP before layering on additional policy changes. Another major part of the letter addressed artificial intelligence.

AHA said AI can help reduce fraud, waste, and abuse and improve care delivery, but only if it is used responsibly. Because of that, the group asked for safeguards such as testing AI coding tools for hallucinations, limiting inappropriate downcoding and automated payment reductions by insurers, requiring insurer transparency on AI use, and protecting independent physician review in coverage decisions.

What was said

According to the letter, “Artificial intelligence (AI) is transforming care delivery in countless ways, supporting increased access, reduced administrative burden and improved outcomes. If used properly, AI tools can also support efforts to mitigate FWA in the health care ecosystem. To support the responsible use of AI, we recommend strategies such as mitigating the risk of hallucinations for AI coding tools through vendor testing, curtailing inappropriate downcoding and automated payment reductions by insurers, ensuring insurer transparency on AI use, as well as clarifying coverage criteria and providing independent physician review of coverage denials.”

Why it matters

The AHA letter does not push back against fraud enforcement itself so much as it argues that CMS should apply the same level of scrutiny to payer practices that it applies to providers. While CMS has expanded its anti-fraud agenda through the CRUSH initiative, the pressure points AHA notes are already visible elsewhere in the system.

According to KFF, nearly 53 million prior authorization determinations were made by Medicare Advantage insurers in 2024, with 4.1 million denied, and HHS OIG has already found that some denials delayed or blocked medically necessary care even when requests met Medicare coverage rules. AHA’s point, then, is that program integrity cannot be measured only by how aggressively regulators chase suspicious billing.

It also has to be measured by whether coverage rules, prior authorization systems, and AI-supported decisions are fair, transparent, and clinically sound. Put differently, CMS is asking how to stop abuse in healthcare. At the same time, hospitals warn that poorly governed insurer conduct and automated decision-making can create a different kind of harm within the same system. That is what makes the letter more than a routine comment submission.

See also: HIPAA Compliant Email: The Definitive Guide (2026 Update)

FAQs

How do AHA, CMS, and HHS OIG connect to each other?

AHA represents hospital interests, CMS writes and enforces program rules, and HHS OIG reviews whether HHS programs are being run lawfully and efficiently. In practice, AHA often comments on CMS proposals, while OIG findings can shape the policy environment around those proposals.

What is a CMS request for information?

A request for information is a formal way for CMS to ask stakeholders for feedback before making or refining policy. Hospitals, trade groups, insurers, and other organizations often respond with comment letters.

Why do hospital groups respond to CMS letters and proposals?

Hospital groups respond because CMS policy can affect payment, compliance burden, patient access, staffing, reporting duties, and operational workflows across the health system.