AHA Responds to CMS RFI on Regulations to Combat Fraud, Waste and Abuse (CRUSH)

March 30, 2026

The Honorable Mehmet Oz, M.D.
Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Submitted Electronically

RE: CMS–6098–NC Request for Information (RFI) Related to Comprehensive Regulations To Uncover Suspicious Healthcare (CRUSH)

Dear Administrator Oz:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS’) Request for Information (RFI) Related to Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH).

The AHA supports CMS’ efforts to combat fraud, waste and abuse (FWA) in federal health care programs by holding accountable actors who flout their legal and compliance obligations. Hospitals are ever mindful of their obligation to properly bill for the services they provide to Medicare, Medicaid and Children’s Health Insurance Program (CHIP) patients and incur great costs to do so. Specifically, we estimate that an average-sized hospital with 161 beds will have to spend more than $562,299 each year on regulatory compliance.¹ Given that hospitals already operate under extensive oversight requirements, we urge CMS to ensure that any regulatory or programmatic changes related to FWA are appropriately data-driven and do not add unnecessary administrative burden for the nation’s hospitals. We look forward to working with the agency on tailored solutions that recognize the majority of providers act responsibly, while appropriately targeting bad actors.

Our specific recommendations follow and are discussed in greater detail in our attached comments.

Certain Medicare Advantage Organization (MAO) coverage and reimbursement practices would benefit from additional regulatory oversight and scrutiny to prevent FWA. These include complex prior authorization requirements and opaque coverage rules, network inadequacy and mid-year changes, restrictive and often proprietary medical necessity or coverage criteria and the impacts of MAO vertical integration. We encourage CMS to use the data it already collects through Medicare Part C and D reporting, as well as MAO conduct providers flag for the agency, to inform audits and other enforcement tools necessary to address these problematic practices. In addition, we urge CMS to clarify that the Medicare Advantage (MA) noninterference clause in Section 1854(a)(6)(B)(iii) of the Social Security Act is not a broad bar on otherwise lawful federal oversight of MA plan compliance and that MAOs cannot evade oversight simply by recategorizing compliance with Medicare coverage rules as merely a private payment matter.

Strong tools to prevent FWA are critical to maintaining public confidence in and sustaining the Medicaid and CHIP programs. Providers, like the states and CMS, are committed to Medicaid and CHIP program integrity and to safeguarding taxpayer resources while ensuring access to care for patients. We recommend that CMS leverage and strengthen its existing oversight tools, processes and transparency requirements in Medicaid and CHIP, and that recent transparency and accountability initiatives be evaluated before any additional policy changes are proposed.

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.

We appreciate your consideration of these issues. Our detailed comments are attached. Please contact me if you have questions or feel free to have a member of your team contact Robyn Tessin, AHA director of payment policy, at rtessin@aha.org.

Sincerely,

/s/

Ashey Thompson
Senior Vice President
Public Policy Analysis & Development

Enclosure

View the details below.

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¹ AHA estimate based on analysis in Regulatory Overload: Assessing the Regulatory Burden on Health
Systems, Hospitals and Post-acute Care Providers (available at https://www.aha.org/system/files/2018-
02/regulatory-overload-report.pdf) and adjusted for hospital expenses in 2024.