Fraud, Waste & Oversight
Expert articles and analysis related to fraud, waste & oversight.
AI Summary â Last 30 Days
In the past 30 days, CMS has intensified oversight and program integrity efforts in Medicare Advantage and ACO models, signaling a pronounced shift toward stricter fraud and waste controls within value-based care. Enforcement actionsâincluding a $556 million Medicare fraud settlement with Kaiser affiliates and UnitedHealthâs recognition of multi-year RADV audit liabilitiesâdemonstrate heightened risk and increased financial exposure for payers amid ongoing OIG risk adjustment audit scrutiny. Meanwhile, CMSâs recent policy movesâsuch as holding ACOs harmless from certain suspect billing practicesâreflect an evolving approach that seeks to balance robust anti-fraud efforts with the preservation of core VBC incentives, underscoring ongoing tensions between regulatory enforcement and payment model stability (âLifesavingâ: ACOs laud federal move to address suspect billing).
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STAT+: CMS to ask every state for new audits of health care providers
The Trump administration has been heavily focused on combating purported fraud in federal health care programs.
New Federal Focus on Fraud, Waste and Abuse May Signal Changes for the Health Care Industry
Metro Detroit Surgeon Was Sentenced to a Year in Prison in $7 Million Dollar Medicare Fraud Scheme - Office of Inspector General (.gov)
Metro Detroit Surgeon Was Sentenced to a Year in Prison in $7 Million Dollar Medicare Fraud Scheme  Office of Inspector General (.gov)
Six St. Louis Area Residents Accused of $8.3 Million Pandemic Fraud - Office of Inspector General (.gov)
Six St. Louis Area Residents Accused of $8.3 Million Pandemic Fraud  Office of Inspector General (.gov)
CMS Has Limited Oversight of Selected Compounded Drugs Prescribed to Medicare Part D Enrollees - Office of Inspector General (.gov)
CMS Has Limited Oversight of Selected Compounded Drugs Prescribed to Medicare Part D Enrollees  Office of Inspector General (.gov)
Attorney General RaĂșl Torrez Announces $6.6 Million Restitution for Mother-Daughter Duo Leading Afterschool Program Medicaid Fraud and Child Identity Theft Scheme - Office of Inspector General (.gov)
Attorney General RaĂșl Torrez Announces $6.6 Million Restitution for Mother-Daughter Duo Leading Afterschool Program Medicaid Fraud and Child Identity Theft Scheme  Office of Inspector General (.gov)
Nine Medicaid Providers Facing Fraud, Theft Charges - Office of Inspector General (.gov)
Nine Medicaid Providers Facing Fraud, Theft Charges  Office of Inspector General (.gov)
Former Teacher Pleads Guilty in $51 Million Medicare Fraud Scheme in National Fraud Enforcement Division Prosecution - Office of Inspector General (.gov)
Former Teacher Pleads Guilty in $51 Million Medicare Fraud Scheme in National Fraud Enforcement Division Prosecution  Office of Inspector General (.gov)
DOJ Announces More Details About the National Fraud Enforcement Division
Clayton Chiropractor Sentenced to 100 Months in Prison - Office of Inspector General (.gov)
Clayton Chiropractor Sentenced to 100 Months in Prison  Office of Inspector General (.gov)