While healthcare cyberattacks have dominated the news lately, healthcare fraud has quietly emerged as an equally concerning issue.
You may remember last year’s Operation Nightingale, whereby almost 8,000 fake nursing diplomas were found to have been issued by three Florida nursing schools. Over two dozen people were charged for their participation in the scheme, and each faced up to 20 years in prison. Prosecutions are ongoing, but recently three of the defendants received their sentences after a three-week jury trial, and now face a combined 147 months in prison.
This week, the U.S. Department of Justice (DOJ) announced criminal charges against 193 people – 76 of them healthcare providers – for their alleged participation in fraud schemes totaling $1.6 billion in actual losses. The schemes related to amniotic wound grafts, the distribution of controlled substances by a digital technology company, adulterated and misbranded HIV meds, addiction treatment, telemedicine and laboratory fraud, and opioids.
Let’s look into a couple of these instances.
One of the more concerning schemes was related to adulterated and mislabeled HIV drugs, whereby owners of a wholesale drug distributor allegedly purchased HIV meds off the black market and resold them to pharmacies around the country. Some patients ended up receiving bottles labeled as their prescription when in fact it was an entirely different drug.
The controlled substances scheme made the news a bit earlier in the month, when the CEO and clinical director of the California digital technology company Done was accused of distributing over 40 million pills of Adderall and similar stimulants to patients over the Internet. The company’s business model allowed for the provision of these drugs in exchange for a monthly subscription fee. At the center of the charges was one nurse practitioner (NP) who prescribed over 1.5 million pills across the country, allegedly without any follow-up encounters. The DOJ alleges that the company used deceptive advertising on social media and specifically targeted drug users. Because of Done’s auto-refill policy, the NP allegedly continued to write prescriptions for patients who were deceased – some due to overdoses.
Several other states saw their own citizens charged in the sweep as well. Healthcare workers in Indiana were charged for stealing drugs and credit and bank information from patients. A provider in Michigan illegally acquired Medicare beneficiary information and submitted claims to Medicare for over-the-counter COVID-19 tests, regardless of whether the patient requested them. A single provider in Wisconsin allegedly received $1.4 million in funds from the Centers for Medicare & Medicaid Services (CMS) for staffing that was not provided.
The DOJ noted that prior to this large enforcement action, the Health Care Fraud Strike Force has charged more than 5,400 defendants who illegally billed over $27 billion since its inception in 2007.
When promising additional future action, Attorney General Merrick Garland stated that “it does not matter if you are a trafficker in a drug cartel…or a medical professional employed by a healthcare company… you WILL be held accountable.” I think we can certainly expect continued attention on fraud foreseeable future.
The Centers for Medicare & Medicaid Services (CMS) operates a surveillance platform called the Fraud Prevention System (FPS) that analyzes Medicare claims across the full
EDITOR’S NOTE: Gloryanne Bryant has more than 40 years of experience in her field and is an independent HIM Coding and CDI Consultant who works
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
