Literature Review

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. 

Period of Enhanced Oversight for new hospices in Arizona, California, Nevada, Texas, Georgia & OhioCMS MLN Fact Sheet; 12/25CMS is placing newly enrolling hospices located in Arizona, California, Nevada, Texas, Georgia, and Ohio in a provisional period of enhanced oversight. We received numerous reports of hospice fraud, waste, and abuse. The number of enrolled hospices has increased significantly in these states, raising serious concerns about market oversaturation. What’s the Goal? The goal of enhanced oversight is to reduce hospice fraud, waste, and abuse.Publisher's Note: The recent addition of Georgia and Ohio is new. More information to follow.

Healthcare fraud enforcement trends to expect in 2026 JD Supra; by Arnall Golden Gregory; 12/8/25Key Takeaways

Combating durable medical equipment fraudOIG video; 11/25/25Durable Medical Equipment (DME) refers to medical devices prescribed by a health care provider to help patients manage health conditions and is essential for millions of people. DME includes medical devices like wheelchairs, oxygen tanks, and glucose monitors. Unfortunately, DME is a frequent target for fraud – costing taxpayers billions of dollars and putting patients at risk. [Click above to view a three-minute video on this topic.]

He built a nursing home empire despite state investigations. Now, lawsuits are piling upCal Matters; by Jocelyn Wiener; 11/20/25California nursing homes affiliated with Shlomo Rechnitz are facing lawsuits alleging that patients were raped, ignored and unnecessarily exposed to COVID-19. His companies deny the allegations. In February 2024, a Los Angeles County jury awarded $2.34 million to an 84-year-old nursing home resident named Betsy Jentz, finding that the facility had violated her rights on 132 occasions, at times leading to serious injuries. [Three more equally offensive cases.] All of these facilities have one thing in common: state records list Shlomo Rechnitz as an owner. Court documents show Rechnitz and his companies have denied all allegations in all of the cases.

Hospice: Track errors, payment caps to avoid facing costly penalties Home Health Line, DecisionHealth; by MaryKent Wolff; 11/13/25 Keep a close eye on possible claim and billing mistakes that could lead to issues related to your payment cap. While increased revenue may seem like a good thing for providers, overpayments could lead to heightened scrutiny and financial hardships for your agency. [May require subscription for additional information]

Integrated clinical-social care and boundaries of health careJAMA Health Forum; by Vincent Guilamo-Ramos, Marco Thimm-Kaiser, Adam Benzekri, Kody H. Kinsley; 10/25After a decade of growing momentum, the future role of health care in addressing patients’ health-related social needs (HRSNs) through integrated clinical-social care is uncertain. There is agreement that increasing health care expenditures are a significant burden on the national budget, but there is disagreement over remedies to reduce costs while improving outcomes. We argue that a constructive debate over the role of integrated clinical-social care within health care reforms requires a shared vision for its implementation. We advance this debate by delineating the boundaries of what the health care system, social welfare system, and bridging infrastructure between them can deliver in an integrated clinical-social care paradigm.

Nurse swapped hospice patient’s medicine with household cleaner in MA, feds say The Herald; by Julia Marnin; 11/4/25 A registered nurse caring for a non-verbal hospice patient in Massachusetts was caught replacing the patient’s liquid pain medication with household cleaner, according to federal prosecutors. Now, a federal indictment charges the nurse, Lori Robertson, of Salem, New Hampshire, with one count of tampering with a consumer product. Federal authorities arrested Robertson, who worked at a long-term care and rehabilitation center in Amesbury, Massachusetts, on Oct. 31, according to court records. She pleaded not guilty at an arraignment that day.

CMS’s Special Focus Facility Program for Nursing Homes has not yielded lasting improvementsOIG press release; 10/29/25This report evaluated the effectiveness of the Centers for Medicare & Medicaid Services’ (CMS) Special Focus Facility (SFF) program, the agency’s flagship effort to address quality problems at the nation’s poorest-performing nursing homes. OIG found nearly two-thirds of facilities that graduated from the SFF program between 2013 and 2022 later exhibited recurring quality issues. Among nursing homes that received a serious deficiency in the three years after graduating, 38% put residents at risk of serious injury, harm, impairment or death. For program improvement, OIG recommended that CMS use more nonfinancial remedies, assess enforcement effectiveness—especially for staffing deficiencies—and incorporate ownership data.Publisher's note: It's interesting to see what works - and what doesn't work - from the CMS / OIG perspective.