Commercial Insurance Fraud

Perpetrators of National ACA Enrollment Fraud Case Sentenced

March 2, 2021 - Update 3/3/2021: This article has been updated to reflect that Jeffrey Yates was indicted as having participated in the Whites' fraud scheme. A previous version said that he was "found guilty," but this was inaccurate as he died in October 2020, according to local news outlets. In a nationwide case, two individuals have been...


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Cigna Embroiled in Lawsuit Over Wellness Program Risk Adjustment

by Kelsey Waddill

A lawsuit was filed against Cigna on August 4, 2020 for $1.4 billion in false and fraudulent risk adjustment claims between 2012 and 2017, according to a court filing obtained by Axios. The...

How to Implement AI Platform to Fight Commercial Insurance Fraud

by Kelsey Waddill

“How do we get in front of commercial insurance fraud issues as early in the scheme as possible?” That is what Kurt Spears constantly asks himself as the vice president of financial...

HHS Charges Dozens in $1.2B Telemedicine, DME Fraud Scheme

by Jessica Kent

One of the largest healthcare fraud schemes investigated by the FBI and HHS and prosecuted by the Department of Justice resulted in $1.2 billion in losses and charges against 24 executives of...

Walgreens Agrees to $296M Settlement in Healthcare Fraud Cases

by Jessica Kent

Walgreens has agreed to pay a total of $296.2 million in settlements for two separate healthcare fraud cases. The first settlement, approved on January 16, 2019, requires the pharmacy chain to pay...

DOJ Recovers $2.5B in Healthcare Fraud, False Claims in 2018

by Jennifer Bresnick

2018 was a bad year to be a healthcare fraudster.  The Department of Justice (DOJ) has announced that $2.5 billion of the total $2.8 billion recovered under the False Claims Act can be attributed...

Robocalls Targeted Consumers During Health Plan Enrollment Period

by Chuck Green

Health insurance open enrollment’s kicked off, accompanied by a spike in automated calls with offers of Affordable Care Act or other health plans, much to the chagrin of...

FTC Clamps Down on Allegedly Fraudulent Health Plans

by Kyle Murphy, PhD

A federal judge temporarily closed a Florida-based firm accused of fraudulently collecting over $100 million from Americans. Simple Health allegedly collected more than $100 million by preying on...

Poor Data Quality in CA Medicaid Drives $4B in Improper Payments

by Thomas Beaton

California's Medicaid program, Medi-Cal, made over $4 billion in improper payments to cover benefits for ineligible beneficiaries because of poor data quality and insufficient oversight, according...

60% of Employers Fail to Address Healthcare Spending Waste

by Thomas Beaton

Sixty percent of employers don’t capitalize on opportunities to address healthcare spending waste, even though they say wasteful spending is a key concern, according to a new survey from the...

BCBS of TN Defrauded $2M in $2B Telemedicine Insurance Scheme

by Thomas Beaton

BlueCross BlueShield (BCBS) of Tennessee has been named a damaged party after it was defrauded $2 million as part of a larger $2 billion telemedicine insurance scheme, according to the Department of...

$36.9M in Medicare Fraud Leads to Federal Convictions, Sentencing

by Thomas Beaton

New high-profile Medicare fraud cases have led to convictions and lengthy prison sentences for providers that attempted to defraud Medicare of $36.9 million. Federal agencies including HHS, the FBI,...

DaVita Medical to Pay $270M for Improper Medicare Advantage Payments

by Thomas Beaton

DaVita Medical Group has agreed to pay $270 million to the Medicare program after identifying suspect billing practices that incorrectly raised its Medicare Advantage payments, says the Department of...

DOJ Nabs 601 Defendants in Biggest Healthcare Fraud Takedown Yet

by Thomas Beaton

HHS Secretary Alex Azar and Attorney General Jeff Sessions have announced the largest healthcare fraud takedown yet after HHS, the Department of Justice (DOJ), and other law enforcement agencies...

Preventing Provider Fraud through Health IT, Data Analytics

by Thomas Beaton

Healthcare fraud is an industry-wide problem can impact a payer’s ability to protect their revenue streams and maintain financial integrity. Fraud costs the nation’s healthcare payers...

Commercial, Public Payer Healthcare Fraud Cases Total $21.6M

by Thomas Beaton

The latest string of commercial and public payer healthcare fraud cases totaled $21.6 million from providers launching various schemes such as patient kickback agreements and false claims...

Former CMS Employee Found Guilty in Insider Trading Scheme

by Thomas Beaton

A former CMS employee leaked high-level information related to the agency’s rulemaking decisions and changes in provider reimbursement as part of an insider trading scheme, according to a guilty...

DoJ Settles $27.68M in Medicare Fraud, False Claims Act Violations

by Thomas Beaton

The Department of Justice continues its crackdown on Medicare fraud by settling various criminal cases related to $27.68 million of False Claims Act violations. Provider settlements remain the primary...

OIG: Medicaid Fraud Control Units Recovered $1.8B in 2017

by Thomas Beaton

Medicaid fraud control units (MFCUs) recovered $1.8 billion in 2017 through effective collaboration with state governments, according a new report released by the Office of the Inspector General...

OIG: Medicare Could Save $367M by Auditing Improper Payments

by Thomas Beaton

CMS auditing systems failed to recognize that 61 percent of Medicare payments for outpatient physical therapy claims in 2013 were improperly filed, which cost the Medicare program nearly $367 million,...