Largest US healthcare fraud case reveals billions in false Medicare, Medicaid claims and vast schemes nationwide

Editor's Note

The US Department of Justice (DOJ) has conducted the largest healthcare fraud takedown in US history, charging 324 individuals, including 96 licensed medical professionals, in schemes totaling more than $14.6 billion, HealthCare Business News July 8 reports. The nationwide crackdown involved 50 federal districts and 12 state attorneys general offices, with law enforcement seizing more than $245 million in assets ranging from cash to cryptocurrency and luxury goods.

As detailed in the article, federal authorities said the operation not only recouped funds but also prevented losses. The Centers for Medicare & Medicaid Services reported $4 billion in fraudulent claims were stopped before payment, and 205 providers had their billing privileges suspended or revoked in advance of the sweep.

Much of the alleged fraud came from complex international networks. One major case, Operation Gold Rush, charged 19 defendants with using stolen identities to submit $10.6 billion in false claims for durable medical equipment. Twelve arrests have been made, with some suspects captured overseas or at US entry points. According to a June 30 The Washington Post article, this scheme spanned more than 30 Medicare-enrolled supply companies, targeting over one million Americans with fraudulent claims for more than a billion urinary catheters and other equipment. Authorities intercepted more than 99% of Medicare payments, but supplemental insurers still lost about $1 billion.

Other cases highlight the breadth of schemes. Charges include a $703 million Medicare fraud involving AI-generated patient consent recordings, a $650 million Arizona Medicaid fraud tied to addiction treatment centers, and more than $1 billion in false billing for amniotic wound grafts, frequently applied to elderly or hospice patients. The DOJ also charged 74 defendants in cases tied to more than 15 million prescription opioid pills, including one Texas pharmacy accused of distributing 3 million pills alone.

Fraud linked to telemedicine and genetic testing accounted for another $1.17 billion in alleged false claims. One Florida-based operation allegedly used deceptive telemarketing to bill for unnecessary genetic testing and medical equipment. Beyond these cases, another 170 defendants face charges involving $1.84 billion in false claims for diagnostic tests, medications, and services that were unnecessary, never provided, or tied to kickback schemes.

A July 24 The Wall Street Journal article reports the crackdown comes as UnitedHealth Group confirmed it is under both civil and criminal investigation by the DOJ over its Medicare billing practices. Regulators are examining whether the company inflated payments by adding diagnoses that may not have reflected true medical need. UnitedHealth has said it is cooperating and plans to conduct independent audits of its processes.

The DOJ also announced the creation of a new Health Care Fraud Data Fusion Center, which will leverage advanced analytics and AI to strengthen coordination across agencies and detect emerging fraud patterns in real time.