Fraud Prevention and Detection

Latest Headlines

Latest Headlines

Florida clinic owner sentenced to 14 years for fraud scheme

A Florida businessman and used three Tampa medical clinics was sentenced to 14 years in prison for a scheme that billed $12.3 million in fraudulent claims to Medicare.

For the 'bounty hunter' of Medicare fraud, cases begin with analytics

Most fraud cases work like this: A whistleblower files a lawsuit or a tip, and investigators scour claims data to support the accusation. However, one personal injury attorney is finding success by working backward, according to  Wired.  

Predictive analytics still has a long way to go in preventing healthcare fraud

Predictive analytics are supposed to be the key to preventing healthcare fraud, but as the latest investigation into compounded pharmaceuticals shows, the industry is still a long way from effectively preventing improper payments. Although the signs of abuse were there, government officials employed a long-standing "Whac-A-Mole" approach to enforcement of compounded drugs, leaving investigators to try to claw back millions of long-gone payments. 

Undercurrent of fraud drives rising hospice payments

The hospice industry has become an easy target for criminals looking to stretch the definition of "terminally ill," thanks to lackluster federal oversight and a low bar for coverage, according to the  Pittsburgh Post-Gazette.  

Doctor accuses Humana of encouraging Medicare Advantage fraud

A recently unsealed lawsuit suit claims Humana encouraged physicians to elevate patient conditions in an effort to inflate Medicare Advantage risk scores, and then turned a blind eye when one physician voiced concerns, according to a report jointly published by the Center for Public Integrity and  NPR.

Fierce Exclusive: After explosion of compounded drug fraud, legal experts say party's over

In April 2015, Tricare spent $545 million on compounded pharmaceuticals, more than 58 times its monthly spending just three years prior. The spike in spending marked the peak of a gradual increase in spending on compound drugs that accelerated during the first several months of 2015 as Tricare was initiating changes to its pharmaceutical formulary. Now, federal investigators are digging into pharmacies that may have relied on marketers to generate referrals, while shielding the true effectiveness and cost of compounded medications.  

Federal fraud recoveries reach $2.4B in 2015

The federal government collected $2.4 billion through the Healthcare Fraud and Abuse Control (HCFAC) program during fiscal year (FY) 2015, nearly one-third less than the previous year.  

Olympus pays $646M to settle kickback allegations

The nation's largest distributor of endoscopes has agreed to pay $646 million to settle criminal and civil claims that the company offered various kickbacks to hospitals and doctors that signed deals to purchase medical equipment, according to the Department of Justice.  

Proposed rule clamps down on providers with a history of fraud

A proposed rule released by the Centers for Medicare and Medicaid Services would expand the power of government officials to deny or revoke billing privileges for providers that pose a risk to federal healthcare programs.

A passive approach to healthcare fraud? That's nothing new

Last week's report from the Government Accountability Office made waves after the agency characterized enrollment fraud detection within the federal Affordable Care Act marketplace as "passive," a word that many latched on to as way of denouncing the president's landmark healthcare legislation. Although the GAO pointed out some valid criticisms of ACA fraud detection, this submissive approach to fraud prevention seems to reflect a widespread systemic issue among government-run programs dating back to the inception of Medicare and Medicaid.