07-07-2025
Using AI to go after health care fraud
WASHINGTON WATCH
The federal government is using artificial intelligence to crack down on health care fraud schemes.
The AI-powered crackdown provides the federal government with a tool to stay ahead of fraudsters and hasten the investigation process.
The effort, orchestrated by the Justice Department, the FBI and HHS's Office of the Inspector General, has led to criminal charges against 324 defendants, including 96 doctors, nurse practitioners, pharmacists and other medical professionals for alleged participation in health care fraud schemes.
Natalia Casella, a spokesperson for the HHS OIG, declined to say how exactly the agencies are using AI in investigations. 'We often do not share this type of information because we are aware that fraudsters are monitoring,' she said.
Cases in point: The DOJ charged an Arizona nurse practitioner with defrauding Medicare by billing elderly Medicare beneficiaries for medically unnecessary treatments, billing the federal health insurance program more than $209 million.
In another case, the DOJ charged a California man who received more than $2 million in kickbacks from treatment facilities for patient referrals for additional treatment. He also paid people to find patients to send to treatment centers.
Additionally, the agency also charged civilians and medical professionals as part of the 324 defendants accused of submitting fraudulent health care and disability claims and prescription opioid trafficking. This batch of fraud amounts to over $14.6 billion, the Justice Department said in a statement.
Why it matters: Health care scams can be a significant drain on the healthcare system, and the Trump administration has emphasized that it aims to go after this. The General Accountability Office estimates 10 percent of healthcare expenditures — or more than $100 billion — are fraud, waste and abuse.
'Health care fraud isn't just theft — it's trafficking in trust,' Robert Murphy, acting administrator of the Drug Enforcement Administration, said in a statement. 'We're targeting the entire ecosystem of fraud — from pill mills in Texas to kickback clinics exploiting Native communities.'
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A federal judge in Washington ordered the Trump administration to restore health data pages posted on Department of Health and Human Services websites, our Lauren Gardner reports.
About the lawsuit: The lawsuit, filed by a liberal-leaning medical advocacy group called Doctors for America, claimed the removal of websites that covered HIV prevention and student health deprived doctors and researchers 'of access to information that is necessary for treating patients' and created a 'dangerous gap in the scientific data for public health emergencies.'But the federal agencies sued — the Office of Personnel Management, the CDC, the FDA and HHS contended the takedown was part of a lawful review to comply with President Donald Trump's executive order to crack down on 'gender ideology and extremism.'
But U.S. District Judge John Bates, who was appointed by former President George W. Bush, characterized the agencies' missives as 'sweeping and poorly thought-through directives' and noted they were issued without public notice or comment.
'An executive order can do a lot, but it does not absolve agencies of their obligations to follow the law,' Bates said in his ruling.
Why it matters: This case, like many others filed against the Trump administration, underscores the power federal judges have as a check on the government's directives.
Bates instructed the plaintiffs to list all HHS webpages and datasets the Doctors for America group relied on by July 11 and ordered the government to restore the versions of the pages that existed as of midnight on Jan. 29 as soon as possible. He also ordered the agencies to file status reports starting July 18 and every following Friday until they've fully complied with the ruling.
'It is heartening to see that the court agrees with doctors, researchers, and patients that the government cannot unlawfully and without explanation remove crucial health information and datasets,' DFA board member Dr. Reshma Ramachandran said in a statement. 'With this ruling, we can provide care for our patients and protect public health based on evidence, rather than ideology.'
HHS didn't immediately comment on the ruling.
