# Healthcare Fraud * **Definition:** The act of deceiving healthcare systems through illegal practices, such as the submission of false claims or misrepresentation, to obtain unauthorized financial benefits from healthcare services. * **Taxonomy:** Healthcare Topics / Healthcare Fraud ## News * Selected news on the topic of **Healthcare Fraud**, for healthcare technology leaders * 3.8K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/27/2025 | [**Texas physician sentenced to prison for $118M fraud scheme**](https://www.beckershospitalreview.com/uncategorized/texas-physician-sentenced-to-prison-for-118m-fraud-scheme/) | [[Beckers Hospital Review]] | | 5/22/2025 | [**Texas physician sentenced for $118M healthcare fraud scheme**](https://www.beckersasc.com/asc-coding-billing-and-collections/texas-physician-sentenced-for-118m-healthcare-fraud-scheme/) | [[Beckers ASC Review]] | | 5/22/2025 | [**'Depraved' Texas doctor convicted of $325M healthcare fraud bought jet, luxury properties**](https://www.yahoo.com/news/depraved-texas-doctor-convicted-325m-155955115.html) | [[Yahoo]] | | 5/5/2025 | [**Nurse practitioner convicted for role in $2M Medicare fraud scheme**](https://www.beckershospitalreview.com/legal-regulatory-issues/nurse-practitioner-convicted-for-role-in-2m-medicare-fraud-scheme/) | [[Beckers Hospital Review]] | | 4/23/2025 | [**Marketing company operators sentenced to prison for roles in $127M fraud scheme**](https://www.beckershospitalreview.com/legal-regulatory-issues/marketing-company-operators-sentenced-to-prison-for-roles-in-127m-fraud-scheme/) | [[Beckers Hospital Review]] | | 4/21/2025 | [**Healthcare Fraud Detection Market Size to Hit USD 15.36 Billion by 2032, Driven ... - Yahoo Finance**](https://finance.yahoo.com/news/healthcare-fraud-detection-market-size-120000635.html) | [[Yahoo Finance]] | | 4/1/2025 | [**Amidst a Surge in Healthcare Fraud, Teakell Law Announces Expanded Focus on ... - Yahoo Finance**](https://finance.yahoo.com/news/amidst-surge-healthcare-fraud-teakell-140000077.html) | [[Yahoo Finance]] | | 3/12/2025 | [**Retrieve Medical Holdings Inc. Announces Letter of Intent to Acquire Curatus LLC, Strengthening Al-Powered Healthcare Solutions**](https://www.healthcareittoday.com/2025/03/12/retrieve-medical-holdings-inc-announces-letter-of-intent-to-acquire-curatus-llc-strengthening-al-powered-healthcare-solutions/) | [[Healthcare IT Today]] | | 3/6/2025 | [**Healthcare Fraud Enforcement Characterized by Unprecedented Uncertainty Amidst ... - PRWeb**](https://www.prweb.com/releases/healthcare-fraud-enforcement-characterized-by-unprecedented-uncertainty-amidst-changes-in-government--key-legal-developments-302394173.html) | [[PRWeb]] | | 2/4/2025 | [**How a physician's $46M conviction could shape Trump's healthcare fraud enforcement**](https://www.beckersasc.com/asc-news/how-a-physicians-46m-conviction-could-shape-trumps-healthcare-fraud-enforcement.html) | [[Beckers ASC Review]] | | 2/3/2025 | [**Healthcare Fraud Analytics Market Size to Worth USD 25.48 Billion by 2033 - Straits Research**](https://finance.yahoo.com/news/healthcare-fraud-analytics-market-size-152100004.html) | [[Yahoo Finance]] | | 1/27/2025 | [**Global Healthcare Biometrics Market Size to Hit USD 48.9 Billion by 2032, Growing at a ...**](https://finance.yahoo.com/news/global-healthcare-biometrics-market-size-131000292.html) | [[Yahoo Finance]] | | 12/19/2024 | [**Navigating the Global Healthcare Fraud Detection Market Landscape (2024 - 2031)**](https://www.linkedin.com/pulse/strategic-market-insights-navigating-global-healthcare-c2esc) | [[Linkedin]] | | 12/13/2024 | [**Operations manager charged for role in $70.6M Medicare fraud scheme**](https://www.beckershospitalreview.com/legal-regulatory-issues/operations-manager-charged-for-role-in-70-6m-medicare-fraud-scheme.html) | [[Beckers Hospital Review]] | | 12/3/2024 | [**Cotiviti Welcomes Seasoned Technology Executive Suvajit Gupta as Chief Technology Officer**](https://www.businesswire.com/news/home/20241203139499/en/Cotiviti-Welcomes-Seasoned-Technology-Executive-Suvajit-Gupta-as-Chief-Technology-Officer) | [[Business Wire]] | | 12/3/2024 | [**Maxton behavioral health clinic agrees to pay $2.5M over state Medicaid fraud claim**](https://www.yahoo.com/news/maxton-behavioral-health-clinic-agrees-214642431.html) | [[Yahoo]] | | 11/26/2024 | [**Remote Patient Monitoring Market to Expand by USD 3.31 Billion (2024-2028), Focus on ...**](https://www.prnewswire.com/news-releases/remote-patient-monitoring-market-to-expand-by-usd-3-31-billion-2024-2028-focus-on-chronic-disease-management-ai-powered-market-evolution---technavio-302315566.html) | [[PR Newswire]] | | 11/25/2024 | [**Healthcare Fraud Detection Market - Industry Trends and Forecast for period from 2024 to 2031**](https://www.linkedin.com/pulse/healthcare-fraud-detection-market-industry-trends-forecast-iufaf) | [[Linkedin]] | | 11/23/2024 | [**Healthcare Fraud Analy Market Expected to See Strong Growth and Competition with a ... - LinkedIn**](https://www.linkedin.com/pulse/healthcare-fraud-analy-market-expected-see-strong-growth-competition-ycx4e) | [[Linkedin]] | | 11/21/2024 | [**Healthcare Fraud Detection Software Market Forecasted by Types and Applications ... - LinkedIn**](https://www.linkedin.com/pulse/healthcare-fraud-detection-software-market-forecasted-types-applications-evsbf) | [[Linkedin]] | | 10/21/2024 | [**Healthcare Fraud Detection Software Market Size, Share, Competitive Landscape and ... - LinkedIn**](https://www.linkedin.com/pulse/healthcare-fraud-detection-software-market-size-share-competitive-rm6lf) | [[Linkedin]] | | 10/17/2024 | [**Healthcare Fraud Analytics Business Research Report 2023-2030: Growing Role of Data ...**](https://finance.yahoo.com/news/healthcare-fraud-analytics-business-research-152300602.html) | [[Yahoo Finance]] | | 7/3/2024 | [**Healthcare Revenue Cycle Management Market Advancements Highlighted by Trend ... - WhaTech**](https://www.whatech.com/og/markets-research/it/851632-healthcare-revenue-cycle-management-market-trend-forecast-till-2032) | whatech.com | | 6/28/2024 | [**Justice Department charges 193 defendants for $2.8B of healthcare fraud**](https://www.fiercehealthcare.com/regulatory/justice-department-charges-193-defendants-28b-healthcare-fraud) | [[FierceHealthcare]] | | 6/28/2024 | [**Navigate the HIPAA Landscape - Info-Tech Research Group**](https://www.infotech.com/research/ss/navigate-the-hipaa-landscape) | infotech.com | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Department of Justice (DOJ)**: The federal agency increasing efforts to combat healthcare fraud, resulting in numerous criminal charges against healthcare professionals. - **Performant Healthcare, Inc.**: A company that has uncovered over $1.3 billion in savings for the Medicare trust fund through advanced technology and analytics aimed at identifying and recovering waste and improper payments. - **Federal Bureau of Investigation (FBI)**: The principal federal investigative agency that collaborates with other agencies to combat healthcare fraud. - **Miguel Saravia**: CEO of Dana Group Associates, pleaded guilty to healthcare fraud involving false billing and upcoding. - **Centers for Medicare & Medicaid Services (CMS)**: A government agency that regulates healthcare billing practices to mitigate fraud. - **HCA Healthcare**: A healthcare provider involved in legal challenges over unnecessary procedures. - **Dr. John Johnson**: Conspired to defraud the U.S. and healthcare fraud through illegal billing practices for urine drug tests. - **Avalon Healthcare Solutions**: Supports federal initiatives to combat fraudulent billing practices in lab testing and telehealth. - **Done Global Inc.**: A telehealth company charged with healthcare fraud for allegedly prescribing ADHD medications improperly. - **Cotiviti**: A healthcare analytics company focused on preventing and managing fraud, waste, and abuse (FWA) throughout the claim payment cycle. - **Presbyterian Healthcare Services**: A healthcare provider facing legal action due to negligence in securing sensitive patient information. - **Thomas P. Fischer**: A whistleblower whose allegations led to the False Claims Act case against Community Health Network. - **Attorney General Merrick Garland**: The U.S. Attorney General who announced a nationwide operation resulting in the charging of 193 individuals for healthcare fraud. - **Community Health Network**: A healthcare organization that recently reached a $135 million settlement in a healthcare fraud case related to overpayment to physicians for patient referrals. - **Theranos**: A company known for fraudulent lab testing practices that impacted patient care. - **Dr. Mehmet Oz**: Nominated administrator of the Centers for Medicare and Medicaid Services, focusing on reducing fraud and waste in healthcare. - **Codoxo**: A leader in AI solutions for healthcare payment integrity, focusing on uncovering improper billing schemes. ### Partnerships and Collaborations - **DOJ and Law Enforcement Agencies**: Collaboration among various federal and state law enforcement agencies to combat healthcare fraud, leading to significant indictments and asset seizures. - **Five Faces and Privy**: Collaborating to enhance patient experiences through digital trust tools to combat healthcare fraud. - **Senior Medicare Patrol Program**: A program that highlights significant recoveries from healthcare fraud, aimed at restoring public confidence. - **Corewell Health and Grand Valley State University**: Collaboration to address nursing staffing shortages, indirectly impacting healthcare fraud by improving overall healthcare delivery. - **Retrieve Medical Holdings and Curatus LLC**: A planned acquisition to enhance healthcare fraud detection capabilities through AI-driven solutions. - **Retrieve Medical Holdings Inc. and Curatus LLC**: An acquisition aimed at enhancing healthcare technology solutions, particularly in AI-driven provider data solutions to prevent healthcare fraud. - **Aspirion and Boost Healthcare**: Aspirion acquired Boost Healthcare to strengthen reimbursement recovery efforts and improve payment accuracy for healthcare providers. - **ALIGNMT AI and Healthcare Financial Management Association (HFMA)**: A partnership to launch a micro-credentialing program aimed at enhancing AI governance skills among healthcare professionals. - **Codoxo and MVP Health Care**: Codoxo's AI platform helped MVP Health Care uncover improper billing schemes. - **HealthLeaders' Mastermind Program**: Discusses the integration of AI in revenue cycle management to improve financial outcomes. ### Innovations, Trends, and Initiatives - **Healthcare Fraud Analytics**: The growing use of advanced analytics and machine learning to detect fraudulent activities in healthcare, driven by increasing fraud incidents. - **Healthcare Fraud Detection Market Growth**: The market is experiencing significant growth due to increasing fraud schemes and regulatory pressures, with a focus on advanced fraud analytics solutions. - **Healthcare Fraud Analytics Market**: Projected to grow from $4.0 billion in 2023 to $17.7 billion by 2030, driven by the need for advanced fraud detection tools. - **Pilot Program by DOJ**: Incentivizes reporting of healthcare fraud with potential monetary rewards for whistleblowers. - **Telehealth Scrutiny**: Increased enforcement actions from the DOJ regarding telehealth-related fraud, particularly during the COVID-19 pandemic. - **Investigation into Fraudulent Billing Practices**: CMS has initiated investigations into fraudulent billing practices related to urinary catheters, highlighting the need for stricter measures to combat healthcare fraud. - **Descriptive Analytics Segment**: Leading the healthcare fraud detection market with a 40.12% share in 2023, effectively identifying historical fraud trends. - **Telehealth Fraud Awareness**: Initiatives like the New York StateWide Senior Action Council's 'Fraud of the Month' program to educate seniors about telehealth fraud risks. - **Telehealth Modernization Act**: Mandates reporting on fraudulent Medicare and Medicaid claims related to lab tests by January 2026. - **Generative AI in Healthcare**: Utilization of AI technologies to improve fraud detection, streamline administrative tasks, and enhance patient care. - **CMS New Rule**: Addresses fraudulent billing practices, particularly concerning urinary catheters, to protect Medicare Shared Savings Program. - **AI and Machine Learning**: Technologies expected to significantly impact healthcare fraud detection and streamline operations, with a focus on compliance with HIPAA regulations. - **AI in Healthcare**: Identified as a top health technology hazard by ECRI, highlighting the need for proper management to mitigate risks associated with misleading results and biases. - **Customer Identity and Access Management (IAM)**: Crucial for protecting against cybersecurity threats and managing user identities in healthcare. - **Telehealth Modernization Act of 2024**: A legislative effort aimed at extending telehealth flexibilities in Medicare, reflecting the ongoing adaptation of healthcare delivery methods. - **AI and Automation in Revenue Cycle Management**: Healthcare providers are increasingly adopting AI and automation to enhance decision-making, compliance, and operational efficiency in billing processes. ### Challenges and Concerns - **Healthcare Fraud**: Fraudulent billing practices undermine public trust and lead to significant financial losses for taxpayers. - **Rising Healthcare Fraud**: The increasing prevalence of healthcare fraud, including unnecessary procedures and fraudulent billing practices, costing taxpayers billions. - **Healthcare Fraud Impact**: Healthcare fraud inflates insurance premiums and exposes patients to unnecessary procedures, contributing to rising healthcare costs. - **Fraudulent Billing Practices**: Common issues include billing for non-existent services and unnecessary procedures, which undermine the integrity of healthcare systems. - **Regulatory Compliance**: Healthcare providers face challenges in complying with anti-fraud regulations, particularly with evolving legal interpretations. - **Telehealth Fraud Risks**: The rise in telehealth has created opportunities for fraudulent activities, necessitating compliance with regulations. - **Data Breaches**: Increasing risk of identity theft and healthcare fraud due to compromised personal and health information. - **Telehealth Risks**: The expansion of telehealth services presents new opportunities for fraud, particularly targeting vulnerable populations like seniors. - **Phishing and Ransomware Threats**: Healthcare providers are warned about the rising threat of phishing and ransomware attacks. - **Cybersecurity Vulnerabilities**: Healthcare systems are increasingly targeted by cybercriminals, leading to significant risks of data breaches and fraudulent activities. - **Identity Theft in Healthcare**: Concerns regarding identity theft in healthcare systems, prompting the need for secure digital solutions. - **Cybersecurity Risks**: The rise in cyberattacks targeting healthcare organizations, leading to data breaches and compromised patient information. - **Rising Denial Rates**: Health system executives are increasingly concerned about elevated denial rates from payers, particularly in Medicare Advantage. - **Cybersecurity Threats**: Healthcare organizations face increasing data breaches and cyberattacks, necessitating robust security measures to protect patient information.