Literature Review

FWA Insights: The top fraud schemes of 2025 COTIVITI | Fraud, Waste, and Abuse; by Erin Rutzler, AHFI, CFE, CHC, CPC; 2/10/26 Throughout 2025, federal and state authorities uncovered schemes involving everything from unnecessary lab tests to fraudulent telehealth services and hospice care. These cases highlight the evolving tactics bad actors use to exploit vulnerabilities—and the urgent need for payers to stay vigilant. While the methods vary, the goal is the same: profit at the expense of patients and payers. In our latest edition of FWA Insights, we break down three major categories of FWA—lab testing, home health and hospice, and telehealth—with real-world examples from 2025 and recommendations for mitigating these risks.

Woman who allegedly stole $3.2m from Medicare boasted about lavish home Complex; by Helen Storms; 2/7/26 A California woman has been arrested after allegedly stealing $3.2 million from Medicare as part of an elaborate hospice scam. The woman, identified as 49-year-old Flor Mora, shared photos of the lavish $4 million dream home she bought from the funds she is accused of stealing before being hit with felony charges. Mora purchased the luxurious seaside home located in the Carmel Highlands in Monterey County, California, in November 2025. It would later be featured in the Washington Street Journal and even voted the House of the Year. Little did voters know that Mora had paid for the early 20th-century style home with reportedly stolen funds.

California AG Bonta charges 7 in Monterey County over hospice fraud scheme totaling $3.2m KSBW 9 Action News, Monterery, CA; by Ricardo Tovar; 2/6/26 California Attorney General Rob Bonta announced that arrests have been made and felony charges filed against seven people in connection with an alleged hospice fraud scheme filed in Monterey County. The total loss to Medi-Cal and Medicare is estimated to be $3,211,419.79, according to Bonta's office. The complaint alleges that the conduct occurred from approximately April 1, 2016, through June 1, 2024 — a period of roughly 8 years and 2 months.

What Salem-area lawmakers are prioritizing for the 2026 session Salem Reporter, Salem, OR; by Rachel Alexander and Hailey Cook; 2/4/26 ... Oregon’s month-long legislative session got underway on Monday, Feb.2. The fast-paced short session occurs in even years. ... Hospice care oversight: SB 1575 would add protections for patients in hospice care. The new rules would include requiring a background check for business owners, ensuring agencies have the financial resources to care for patients and pausing the issuance of new hospice licenses until the state rules are implemented.  Patterson said the change was at the request of the Oregon Hospice and Palliative Care Association. “In other states there has been a lot of fraud and abuse, and we want to prevent that from happening here in Oregon,” she said. 

O&I Subcommittee holds hearing on ongoing fraud in Medicare and Medicaid programs Energy & Commerce - Chairman Brett Guthrie, Washington, DC; Press Release; 2/3/26 Today [2/3], Congressman John Joyce, M.D. (PA-13), Chairman of the Subcommittee on Oversight and Investigations, led a hearing titled Common Schemes, Real Harm: Examining Fraud in Medicare and Medicaid. ... Watch the full hearing here. [Key excerpts:] ... Congressman Buddy Carter (GA-01): “Auditors found 112 hospice providers operating out of a single physical address. 112...holy cow. As a result, hospice agencies in LA County alone likely overbilled Medicare by $105 million in just one year. […] It looks like it’s a problem in a lot of different places. 

Los Angeles County hospice industry under scrutiny for suspected Medicare fraud Santa Monica Observer, Santa Monica, CA; by Chet McSnark; 2/1/26 With 2,000 hospice agencies, Los Angeles County has more than 36 states combined and 30x more than Florida and New York. ... Recent reports indicate that the county accounts for approximately 18% of the nation's total Medicare billing for these services, despite representing only about 2.5% of the U.S. population. According to statements from CMS Administrator Dr. Mehmet Oz ... has estimated that fraudulent activity in Los Angeles County hospice and home health care could amount to roughly $3.5 billion annually. Federal data shows the county hosts nearly 1,923 hospice providers, a number that exceeds the total in many other states combined.

California revokes 280 hospice licenses in fraud fight; Congressional hearing set Hospice News; by Holly Vossel; 1/28/26 California Gov. Gavin Newsom (D) has provided an update on how the state is tackling fraudulent activity in the hospice space amid rising federal concerns. More than 280 licenses have been revoked among new hospice operators entering the state during the last two years, the governor reported on Tuesday. ... CMS Administrator Dr. Mehmet Oz and other agency officials visited hospices in California and Nevada earlier this month, pledging greater efforts to combat fraud.

Fighting hospice fraud an OIG priority Hospice News; by Jim Parker; 1/26/26 The U.S. Department of Health & Human Services (HHS) Office of the Inspector General (OIG) has identified hospice fraud among top management and performance challenges. This is according to an annual document that OIG prepares, a statutory requirement that is designed to help HHS improve the effectiveness and efficiency of its operations. A major challenge for HHS is the “sizable” reduction in workforce and a slew of program changes instituted by the Trump Administration, the report indicated. “Effectively managing a changing organizational and workforce environment is itself a significant management challenge,” OIG said in the report. 

False Claims Act insights - the rise of state False Claims Act enforcement Husch Blackwell | Thought Leadership; podcast hosted by Jonathan Porter with Rebecca Furdek and Todd Gee; 1/12/26 Our conversation starts with an overview of state False Claims Acts and how the use of FCA varies from state to state. We examine recent settlements in Massachusetts and Minnesota that show the reach of state False Claims Acts and discuss a large District of Columbia False Claims Act settlement for tax liability that could be the next big enforcement area for state-level False Claims Acts.

Kaiser Permanente affiliates settle Medicare risk adjustment fraud case for $556 million JD Supra; by Emily Ann Farmer, Lindsey Brown Fetzer, Brian Roark, Julia Tamulis - Bass, Berry & Sims PLC; 1/19/26 On January 14, the Department of Justice (DOJ) announced that five Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that they violated the False Claims Act (FCA) by submitting unsupported diagnosis codes for Medicare Advantage (MA) beneficiaries to increase reimbursement from the federal government. The relators will receive approximately $95 million as their share of the recovery. ... At $556 million, this represents the largest FCA settlement involving allegations of MA risk adjustment fraud to date, far eclipsing prior MA risk‑adjustment settlements, including Cigna ($172 million, 2023) and Independent Health ($100 million, 2024).

Investigating hospice fraud: Common schemes and red flags Healthcare Fraud Shield; by Rebecca Kneipp; 1/14/26 Hospice is designed to provide comfort and supportive care to terminally ill patients with a prognosis of six months or less. However, the high per diem payment structure makes it a significant target for sophisticated fraud schemes. Improper billing for hospice services not only costs taxpayers millions but can also harm vulnerable patients by denying them necessary care. Understanding the primary modes of operation is crucial for identifying and hopefully preventing millions in improper payments. 

Alliance joins Dr. Oz, CMS leadership, to strengthen program integrity in home health and hospice National Alliance for Care at Home; Press Release; 1/9/26 On January 9, the National Alliance for Care at Home (the Alliance) continued its collaboration with CMS by attending a listening session in Los Angeles, CA, with Dr. Mehmet Oz, Administrator of the Centers for Medicare & Medicaid Services (CMS), Kim Brandt, Deputy Administrator Chief Operating Officer, and Director of the Center for Program Integrity for CMS, and Chris Klomp, Deputy Administrator for CMS and Director of the Center for Medicare, to discuss fraud, waste, and abuse in home health and hospice. ... View the full letter for a detailed list of recommendations. 

US Department of Justice and Dr. Oz targeting California over alleged medical fraud  ABC-7 Los Angeles, CA; by Anabel Munoz The Department of Justice is investigating what it's calling medical fraud in California. First Assistant U.S. Attorney Bill Essayli and Dr. Mehmet Oz held a brief news conference in Los Angeles on Friday to say they're targeting the state of California over the alleged fraud. ... "The patients don't realize they're signing up for hospice, so they're giving up their medical ability to take care of themselves. They're moving outside the health care system, where doctors no longer will care for them because they're in hospice," Oz said.