May 19, 2026 Fraud, Abuse & False Claims Enforcement The Justice Department’s Civil Division launched the FOCUS (Fraud Oversight through Careful Use of Statistics) initiative to formalize its relationship with data miners filing qui tam complaints under the False Claims Act. Qui tam filings have surged in recent years, driven increasingly by data miners — companies or individuals who analyze public government data for fraud signals — rather than traditional insider whistleblowers. Under...
7 days ago • 9 min read
May 19, 2026 Cybersecurity, Data Privacy & HIPAA Fragmented identity systems across healthcare force patients to maintain separate credentials for patient portals, EHRs, pharmacies, PBM claims platforms, and insurer authorization — multiplying security risks and driving the average cost of a healthcare data breach to $7.42 million in 2025, the highest of any industry for the 12th consecutive year. Most breaches are credential-driven, yet the majority of healthcare organizations still rely on...
14 days ago • 12 min read
May 19, 2026 Fraud, Abuse & Government Enforcement The HHS Office of Inspector General will not impose sanctions on a Medicare Advantage organization that proposes to share a percentage of its savings with employer groups through its Employer Group Waiver Plans. The arrangement would involve the MA organization making “Gainshare Payments” to groups such as employers, trusts, and unions when a negotiated medical expense ratio falls below an agreed-upon target, with payments typically issued in...
21 days ago • 14 min read
May 19, 2026 Fraud, Abuse & Enforcement The Texas Health and Human Services Office of Inspector General recovered more than $95.7 million from home health providers between December 1, 2025, and February 28, 2026, according to its quarterly report. Home health agencies accounted for 21 percent of preliminary investigations and 15 percent of full-scale investigations during this period. The agency identified four primary billing errors: failure to have registered nurses perform in-home...
28 days ago • 11 min read
May 19, 2026 Fraud, Abuse & Enforcement Aetna agreed to pay $115 million to settle allegations that it manipulated diagnosis codes to inflate risk scores for Medicare Advantage enrollees. A former risk-adjustment coding auditor filed the lawsuit on behalf of the federal government, claiming Aetna received inflated payments from the Centers for Medicare & Medicaid Services through a process known as upcoding. The Department of Justice alleged that in 2015, Aetna conducted chart reviews and...
about 1 month ago • 8 min read
May 19, 2026 Healthcare Transactions & Private Equity Private equity firms have invested over $1 trillion in debt-financed healthcare transactions over the past decade, with 93% of healthcare companies carrying speculative debt being private equity-sponsored. A JAMA 2023 study showed a 25% increase in complications such as infections and falls following private equity investment in healthcare facilities. Private equity-sponsored healthcare businesses face a 10X increased risk of insolvency...
about 1 month ago • 8 min read
May 19, 2026 Fraud & False Claims Act Enforcement The U.S. Department of Justice recovered more than $6.8 billion in False Claims Act settlements and judgments in fiscal year 2025, marking the largest annual total in the statute’s history. The DOJ reported 1,297 qui tam actions filed by whistleblowers and 401 government investigations during the year. Health care matters accounted for more than $5.7 billion of the total recoveries, with the DOJ focusing on managed care, prescription drugs,...
about 2 months ago • 10 min read
May 19, 2026 Fraud & Abuse / Anti-Kickback The OIG issued a favorable advisory opinion allowing a medical device manufacturer to subsidize Medicare cost-sharing obligations for patients enrolled in a clinical trial testing an implantable device that delivers electrical pulses to baroreceptors in the carotid artery. The study will test the device in heart failure patients with left ventricular ejection fraction between 35 and 50 percent, enrolling up to 2,500 participants at up to 200 sites in...
about 2 months ago • 10 min read
May 19, 2026 Healthcare Fraud and False Claims Aetna Inc. agreed to pay $117,700,000 to resolve allegations that it violated the False Claims Act by submitting inaccurate diagnosis codes for Medicare Advantage enrollees to inflate payments from the Centers for Medicare & Medicaid Services. The government alleged that in 2015, Aetna operated a chart review program that added diagnosis codes to obtain payments but failed to delete codes that chart reviews showed were unsupported, which would...
2 months ago • 13 min read