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We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com. Back to Healio Key takeaways: The U.S. Department of Justice charged 455 defendants for $6.5 billion in alleged false CMS claims. However, experts urged for distinction between fraud and mistakes driven by regulatory complexity. On June 23, the U.S. Department of Justice announced it had charged 455 defendants, including 90 physicians and other licensed health care professionals, with more than $6.5 billion in health care fraud and prescription opioid diversion. The 2026 National Health Care Fraud Takedown included all 50 state Medicaid Fraud Control Units, international law enforcement partners and seizures totaling more than $182 million in assets, according to the DOJ.
Attorney Mark J. Silberman, JD, vice chair of the health care practice group at Benesch law firm, compared the fraud enforcement action to photos of seized contraband taken by law enforcement after drug busts. Mark J. Silberman, JD \u201cThis is the health care fraud equivalent, with the exception that it\u2019s like they took a year and a half\u2019s worth of cases and piled them up on one table,\u201d Silberman told Healio. \u201cAs someone who represents lots of providers, institutions, businesses and systems in these types of cases, the government has every right to audit and make sure that they\u2019re getting the benefit of their bargain,\u201d he added. \u201cBut missing in these efforts is an independent assessment distinguishing between an effort to defraud the government and an honest mistake that results from an unnecessary, complex regulatory structure.\u201d Federal investigations into potential CMS fraud continue. In July, CMS and HHS deferred over $1 billion in Medicaid payments to California and Minnesota pending receipt of further documentation. Compared with last year\u2019s Medicare and Medicaid fraud investigation \u2014 which involved 324 defendants and $14.6 billion in losses \u2014 the 2026 operation was larger in scale but smaller in dollar value. Although only 90 defendants were doctors or other medical professionals, CMS took action to suspend or revoke billing privileges for nearly 2,500 clinicians. \u201cThey\u2019re not going to be allowed to see patients with government insurance, and in many respects, they\u2019re basically put out of business,\u201d Allan Gibofsky, MD, JD, MACR, FACP, FCLM, professor of medicine at Weill Cornell Medicine, told Healio. Fraud or \u2018honest mistake\u2019? Silberman noted that while large-scale Medicare and Medicaid fraud enforcement actions are not unique to the Trump administration, this year\u2019s results are \u201cnot unexpected, if you consider the pressure the current administration has been giving on increasing health care fraud enforcement.\u201d Among the fraudulent actions alleged: $38 million in adult day-care overbilling for services that were never provided in New York, a $49 million crisis stabilization services scam targeting the homeless in Virginia and $44 million in fraudulent behavioral-health claims in Arizona. These cases make up a fraction of the alleged $6.5 billion in fraud identified in the investigation. \u201cWhile the $6.5 billion figure certainly includes allegations of actual fraud \u2014 people making up services or services that weren\u2019t provided \u2014 a portion of this is framed as fraud that are actually cases that involve some hyper-technical regulatory violation or documentation errors,\u201d Silberman said. Investigative methodology is evolving, too, as AI and data analytic tools are increasingly being used to identify suspicious billing activity. \u201cThe government is not concerned about an honest mistake, but a pattern of honest mistakes will be looked at as the possibility of a non-honest mistake,\u201d Gibofsky said. \u201cThat\u2019s where the average practitioner begins to get into murky and deeper waters.\u201d Small errors can snowball into larger problems over time. \u201cYou don\u2019t make 1,000 mistakes in health care,\u201d Silberman said. \u201cYou make one mistake, which gets repeated 1,000 times, because if you set up your documentation wrong or misunderstand one of the complex rules and regulations, then it gets repeated every single time you see a patient.\u201d Protecting practices, patients Clinicians can take steps to safeguard their legal use of Medicare and Medicaid programs. An honest mistake is more likely to be viewed as honest if clinicians maintain solid documentation verification and data integrity, according to Peter Justen, founder and CEO of AmeriTrust Solutions, a company that helps streamline Medicaid intake processes and catch improper payments. Peter Justen \u201cThe strongest fraud prevention strategy is to reduce opportunities for bad information to enter the system, and if I were a clinician, that\u2019s where I would start,\u201d Justen said. \u201cPrevention is always less expensive than recovery.\u201d Clinicians should ensure patients are receiving appropriate care at their practices, as well as outside vendors and institutions to which they are referred. \u201cWhen referring a patient for durable goods, services or specialized care, [ensure] the suppliers are bonafide and not a storefront, which may entrap the patient in a kickback or rebate scheme, denying the patient the services that the practitioners seek to provide,\u201d Gibofsky said. He identified several areas of concern for the average practitioner. \u201cKnow who you\u2019re referring to, don\u2019t provide more services than you say you are, don\u2019t allow your billing company \u2014 many people use third-party companies \u2014 to up-code, particularly if you are reimbursing them on a portion of recovery,\u201d Gibofsky said. While AI scribes have been helpful in reducing burnout among clinicians, they do carry risks when unmonitored. \u201c[Clinicians] have to be certain \u2014 particularly if they\u2019re using electronic scribes \u2014 that the information they\u2019re entering into the medical record is accurate and complete,\u201d Gibofsky said. \u201cArtificial intelligence has been known to hallucinate and make things up, and once you put something into the record, it\u2019s very difficult to get out.\u201d Gibofsky emphasized that physicians become responsible for everything in the medical record after they have signed off on it. Silberman also advised clinicians<\/p>\n","protected":false},"author":1,"featured_media":3268,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-3267","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/3267","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3267"}],"version-history":[{"count":0,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/posts\/3267\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=\/wp\/v2\/media\/3268"}],"wp:attachment":[{"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3267"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3267"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drsoniafawad.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3267"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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