Health Care

Fraudsters steal pandemic cash in your name, infect business web gateways, and pilfer children’s health insurance money and PII

Fraudsters stole billions from U.S. federal COVID-19 loan programs. Now unsuspecting victims, who never applied for those loans, are receiving bills. Plus, business ‘NetScaler Gateways’ are attacked, and Medicaid children’s health insurance recipients are scammed.

5 most scandalous fraud cases of 2023

We’d just filed our Most Scandalous Frauds story of 2022 when news of the implosion of multibillion-dollar crypto exchange FTX broke. It might’ve been a little too late for us to add what would become the biggest fraud scandal since Theranos to the 2022 list, but the FTX story didn’t disappear, and we had FTX founder Sam Bankman-Fried’s trial and eventual guilty verdict to keep us riveted. Of course, FTX wasn’t the only high-profile case that shocked us; there were many others that had a big impact on the anti-fraud profession. Here are the five fraud cases we found most scandalous in 2023.

Fraud lessons from the ‘killer nurse’

Charles Cullen, a former registered nurse, is serving 11 consecutive life sentences for murdering 29 patients in 16 years at New Jersey and Pennsylvania hospitals. The author, who helped investigate the case, shares organizational deficiencies that have helped him in subsequent fraud investigations.

Treating fraud in independent pharmacies

Fraud in independent pharmacies has proliferated in recent years, especially during the pandemic. Here we discuss the different types of pharmacy schemes and what to do about them.

Use advanced tools to fight Medicare fraud

ACFE President and CEO Bruce Dorris, J.D., CFE, CPA, discusses the importance of fighting against algorithmic manipulation and data mining in the Medicare Advantage system.

5 most scandalous fraud cases of 2022

Each year the ACFE, along with input from our Advisory Council, selects the five most scandalous fraud stories of the year based on money lost, lives impacted and relevance to the anti-fraud profession. It’s another year, and we have a brand-new list.

The Medicare disadvantage

Medicare Advantage, the private-sector arm for elderly care, is fast becoming the new battle front in the fight against health care fraud in the U.S. Here's why, and what fraud examiners think should be done.

Catching health care fraud with statistical graphics

Inflating codes that determine how much Medicare and Medicaid pay to health care providers is common practice among fraudsters. Now they’re doing it in increasingly sophisticated ways. Here we examine how statistical graphics can help spot upcoding in what can be an arcane and complicated billing process.

Stanch the flow

Fraudsters have stolen an unprecedented amount of U.S. COVID-19 relief funds — possibly more than the GDPs of many world economies. But millions of dollars had already been streaming from government programs long before the pandemic, and those cases hold valuable lessons. Here’s how to stanch the flow of money from vulnerable agencies.

Phony drug rehab facilities addicted to fraud

When the U.S. Affordable Care Act was enacted in 2010, the for-profit drug rehab industry was essentially given a blank check to treat people struggling with addiction. In the decade since, many of these underregulated businesses — rife with fraud, waste and abuse — have commoditized addicts. Through the lens of a recent high-profile criminal case in California, here’s the background on the issue, and some advice from experts on how to combat this unique type of provider fraud.

Running a marathon at a sprinter's pace

The U.S. Congress has approved a record $5 trillion in aid packages so far to help Americans survive the pandemic, opening up new territory for fraudsters to ply their trade. Fraud Magazine talks to two of the top professionals leading the government’s fight against fraud and finds out why CFEs are required more than ever.

CFEs can be medical practices' best friends

Most medical office practices trust their employees to handle daily financial matters. But what do they do when they catch long-term, trusted employees stealing? Here’s information you can use if you might be looking for medical-practice fraud detection and prevention business, and want to help doctors mitigate losses and claim restitution.