Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Medicare Fraud

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

January 3, 2019 - 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 to fraud and improper claims from healthcare providers during the fiscal year. This was the ninth consecutive year that civil healthcare fraud settlements and judgments have topped $2...


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Risk Scores at Center of Sutter-DoJ Medicare Advantage Dispute

by Kyle Murphy, PhD

A complaint against Sutter Health and Palo Alto Medical Foundation over appropriate risk scores has drawn the attention of the Department of Justice. The federal agency officially announced its intervention into a lawsuit that alleges...

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 consumers shopping for health insurance by...

$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, the Department of Justice (DoJ), and...

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 Justice (DOJ). The improper MA...

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 charged 601 healthcare professionals for $2...

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 submissions. Public payer programs are frequently...

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 medium for healthcare fraud...

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). MFCUs recovered $6.52 for every...

Latest Medicare Fraud Schemes Targeted $139.4M via Kickbacks

by Thomas Beaton

Three Medicare fraud schemes in recent weeks have targeted a total $139.4 million, which led the Department of Justice (DoJ) to seek multiple convictions and a combined 33 years in prison sentences. Each of the schemes involved the use of...

Medicare Fraud Cases Lead to Mix of Convictions, Settlements

by Thomas Beaton

The Department of Justice’s (DoJ) crackdown on Medicare fraud continued as new investigations led to one provider conviction and two multi-million dollar settlements with provider organizations. The conviction found a provider...

Provider Health Insurance Fraud Schemes, Settlements Top $310M

by Thomas Beaton

Law enforcement agencies and federal healthcare administrators including HHS, the Office of the Inspector General (OIG), the FBI, and US Attorney's Offices across the country investigated provider healthcare schemes that defrauded...

DoJ Recovered $2.4B from Healthcare Fraud Schemes in 2017

by Thomas Beaton

The Department of Justice (DoJ) recovered $2.4 billion from federal healthcare fraud cases during 2017, the agency announced in a press release. Healthcare-related fraud recoveries accounted for 64 percent of the DoJ’s $3.7 billion...

Top 5 Most Common Healthcare Provider Fraud Activities

by Thomas Beaton

Healthcare provider fraud is extraordinarily common and can be conducted at a shockingly large scale.  The largest healthcare provider fraud takedown in US history was announced just recently, resulting charges against 400 defendants...

Providers Caught in Medicare Fraud Schemes Topping $200M

by Thomas Beaton

Law enforcement officials continue to crack down on Medicare fraud schemes that siphon millions of dollars from the programs, as individuals submit fraudulent claims or overcharge for unnecessary healthcare utilization. Federal law...

Claims Analytics Help Medicare Identify, Prevent Provider Fraud

by Thomas Beaton

Close to a quarter of new Medicare fraud investigations started with the use of a claims analytics platform that has helped to save approximately $6.7 million in incorrect billings, a new GAO report found.   After reviewing fraud...

DoJ Charges 412 in Medicare Fraud Schemes Totaling $1.3B

by Thomas Beaton

The Department of Justice (DoJ) announced the largest ever healthcare enforcement action in the history of the federal agency took place when the Medicare Fraud Strike Force (MFSF) charged 412 defendants for Medicare fraud losses totaling...

GAO: CMS Erroneously Paid $16B to Medicare Advantage Orgs

by Thomas Beaton

CMS incorrectly paid $16 billion to Medicare Advantage organizations (MAOs) as a result of insufficient oversight and mismanagement of data, says the Government Accountability Office (GAO) in a new report. Almost 10 percent of all MA...

3 Whistleblower Suits Net over $60 Million in Medicare Fraud

by Jesse Migneault

Whistleblower lawsuits alleging Medicare fraud have been settled against two diagnostic testing companies, and a California doctor who was alleged to have falsely diagnosed cancer as a means to bill Medicare for expensive...

Two Payers Liable for $32.5M in Medicare Advantage Fraud Suit

by Jesse Migneault

Insurers Freedom Health and Optimum Healthcare have agreed to pay $32.5 million to avoid further litigation in a whistleblower lawsuit which alleges systemic Medicare Advantage fraud.    The insurers will pay the federal...

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