Medicare Fraud

DOJ Intervenes in Whistleblower Cases Alleging Medicare Fraud

August 3, 2021 - The Department of Justice (DOJ) will intervene in the case of six whistleblower lawsuits against Kaiser Permanente regarding Medicare Advantage diagnosis codes and alleged Medicare fraud. The lawsuits argued that, months or more than a year after patients’ encounters took place, Kaiser Permanente pushed providers to submit information that...

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Payer to Fork Over $6.3M For Medicare Advantage Fraud Allegations

by Kelsey Waddill

Kaiser Foundation Health Plan of Washington will pay over $6.3 million for submitting invalid Medicare Advantage diagnoses, according to the Department of Justice (DOJ). “When insurance...

CMS Considers AI and Value-Based Care Fraud Prevention Strategies

by Kelsey Waddill

CMS sent out two requests for information, one on program integrity issues regarding the fee-for-service to value-based care transition and the other on how to evolve data analytics and artificial...

CMS Finalizes Rule to Crack Down on Medicare, Medicaid Fraud

by Kelsey Waddill

A CMS rule expands its ability to revoke or deny providers’ position serving in federal networks in an effort to combat fraud in Medicare, Medicaid, and CHIP. “The provisions we are...

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...

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...

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...

$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...

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...

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...

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...

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...

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...

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...

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,...

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...

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...

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