Payment Models, Fraud & Compliance

The 2026 score sets the 2028 payment

MIPS Value Pathways gained 6 new options for 2026. CMS's proposed CY 2027 rule, proposed July 2026 and not final as of this review (no final CY 2027 physician fee schedule rule found in the Federal Register on 2026-11-02; check it), would sunset traditional MIPS reporting beginning with the 2029 performance period.

MACRA created two tracks: MIPS and Advanced APMs

Congress has changed the incentive percentages repeatedly; these are the amounts in the statute as of 2026-11-02. The CY 2026 Medicare conversion factors are $33.57 for qualifying APM participants and $33.40 for all other clinicians; the factors reset every year.

"Knowing" includes deliberate ignorance and reckless disregard

DOJ normally adjusts the penalty range for inflation each year, so check 28 CFR 85.5; the OIG Roadmap still prints the older $11,000 figure. A claim resulting from a kickback or a Stark violation may itself be false, creating False Claims Act liability on top of the underlying law. There is also a criminal False Claims Act.

A criminal law: knowing and willful

Strict liability: no intent required

CMS's page states the Stark bar for Medicare; OIG's Roadmap includes Medicaid. The NP point is inferred from the definitions in 42 U.S.C. 1395x(r) and 42 CFR 411.351; no CMS statement specific to NPs was found, and NP arrangements with physicians still need legal review. Designated health services: clinical lab; PT, OT and speech therapy; radiology and imaging; radiation therapy; DME; parenteral and enteral nutrition; prosthetics and orthotics; home health; outpatient drugs; and hospital services.

The 60-day deadline can be suspended during a timely good-faith investigation of related overpayments, for up to 180 days.

Since Program Year 2021, Open Payments covers nurse practitioners, physician assistants, clinical nurse specialists, CRNAs, anesthesiologist assistants and nurse midwives, so industry payments to NPs are publicly reported.