Medicare and Medicaid Regulatory Compliance Issues in 2025

The regulatory climate surrounding Medicare and Medicaid is constantly evolving, with recent years marked by heightened enforcement, expanded program integrity tools, and increased scrutiny on providers, both institutional and individual. As we move further into 2025, federal and state agencies are doubling down on efforts to prevent fraud, waste, and abuse. The stakes have never been higher for healthcare providers who rely on government reimbursement.

In this session, “Cracking the Code: Navigating Medicare & Medicaid Compliance in 2025,” veteran healthcare attorney Knicole Emanuel, who has defended providers against audits, prepayment suspensions, extrapolated overpayments, and False Claims Act allegations for over two decades, breaks down the most pressing compliance challenges providers are facing today.

Participants will walk away with a deeper understanding of the legal and practical frameworks governing Medicare and Medicaid participation, billing, and reimbursement. This session will cover how CMS contractors (such as UPICs, MACs, SMRCs, and RACs) interact and how their growing use of AI and data analytics is shaping the next wave of audits. We’ll also examine the uptick in Medicaid Managed Care scrutiny, with states now mirroring CMS audit tactics and targeting network adequacy, prior authorization delays, and payment denials.

The webinar will provide real-world examples of providers who have been subjected to overzealous enforcement, including the pitfalls of over-documentation, improper modifier use, and extrapolation methodologies. It will also offer survival strategies for responding to audits, appealing denials, and building an internal culture of compliance that balances regulatory demands with operational realities.

• Attendees will also gain insights into emerging risks, such as:
• Increased scrutiny of telehealth billing post-pandemic
• The revival of the 60-day overpayment refund enforcement
• Medical necessity denials driven by AI-based algorithms
• Expanded Medicaid redetermination audits due to PHE unwinding
• Intersection of Medicare Advantage plans and state enforcement authority

This presentation is not just a review of the rules — it’s a strategy session for navigating them. You’ll receive practical tips for audit readiness, key indicators that place your organization at risk, and how to mitigate exposure through documentation, training, and proactive legal review.

Whether you're looking to understand recent OIG work plan items, avoid extrapolated repayment demands, or simply build a more defensible compliance infrastructure, this webinar offers indispensable knowledge that can help you avoid devastating financial and reputational consequences.

Areas Covered in the Session:-

• Current CMS and state audit trends in 2025
• Understanding audit contractors: UPICs, MACs, RACs, SMRCs
• Telehealth compliance risks post-COVID
• Medicaid Managed Care compliance: network adequacy, prior authorizations, denials
• Defending against extrapolated overpayment demands
• The 60-Day Overpayment Rule: practical pitfalls and strategies
• Preparing for audits: documentation, appeals, and internal responses
• Identifying high-risk billing patterns and EHR vulnerabilities
• Medical necessity vs. coding errors: When denials become legal threats
• Provider rights and due process in Medicaid terminations and suspensions
• Creating a compliance culture that’s realistic, proactive, and legally sound.

Background:-

Medicare and Medicaid are the backbone of the U.S. healthcare system, collectively providing coverage to over 150 million Americans. With that scale comes complexity, and with complexity comes risk. Recent enforcement trends show that federal and state regulators are ramping up audits, False Claims Act cases, and overpayment recoupments, often based on minute documentation or coding errors.

As 2025 unfolds, healthcare providers face an increasingly aggressive regulatory landscape. Understanding the nuances of compliance — from documentation and billing to managed care oversight — has never been more critical.

Why Should You Attend?

Whether you're a compliance officer, legal counsel, practice administrator, or healthcare executive, this session will give you practical, actionable insights into staying compliant in today’s evolving Medicare and Medicaid regulatory environment. With enforcement priorities shifting and audit targets broadening, attending this webinar could help you prevent costly penalties, protect your reputation, and ensure operational stability.

Who Will Benefit?

Health care executives, legal, compliance, CEO, Dental, DMW, hospitals, long-term care, and anyone who accepts Medicare and Medicaid.