By David Lareau – Medicare Advantage oversight has entered a more data-driven phase, with regulators focusing closely on how diagnoses are identified, documented, and submitted for risk adjustment. At the center of that scrutiny is the practice of “suspecting,” which involves searching patients’ medical records to identify…
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By Erin Rutzler – The new year brings with it all kinds of new opportunities for healthcare fraud, waste, and abuse (FWA) from bad actors. As FWA trends remain as relevant as ever in 2026, one common scheme to stay vigilant against is “phantom providers.”
By Zac Amos – Artificial intelligence powers healthcare operations, clinical decision support and administrative efficiency, but cybercriminals use the same tools to carry out more convincing, scalable and adaptive fraud. AI-enabled schemes exploit complex systems, data and human trust, making strong governance, technical controls and organizational awareness essential.
By David R. Burda – Here are the DOJ stats released on Feb. 22 for civil fraud and false claims settlements and judgments recovered for taxpayers by the agency in fiscal 2023, or from Oct. 1, 2022, through Sept. 30, 2023.
By Art Gross – Far too often, and in just about every industry, those of us who are “in it” assumes that certain aspects of what we know are obvious to the general public. For example, in healthcare, we know the basics of HIPAA and what information can and cannot be shared.
By Susan Walberg JD – The COVID-19 pandemic has brought with it huge challenges for people all over the world; not only the obvious health-related concerns but also shutdowns, unemployment, financial difficulties, and a variety of lifestyle changes as a result.
By Julie Sheppard – Compliance professionals agree that training the workforce is a major component of a successful compliance program. In fact, employee education is an important first step toward preventing, detecting, and mitigating noncompliance.
By Emad Rizk MD – COVID-19 exposed many weaknesses in our healthcare system and exacerbated fraud, waste and abuse. As the federal government waived restrictions around various reimbursements for Medicare patients as well as encouraged plans to be more…
By Matt Fisher – It seems as though multiple times per year the Department of Justice, HHS, or some other enforcement agency announces the largest sweep or takedown of health care related fraud. A joint Department of Justice and HHS announcement on June 22, 2016 is the latest example.