Final yr, we wrote within the Los Angeles Instances that the Facilities for Medicare and Medicaid Companies was accomplished chasing criminals after we’d already handed them cash. We mentioned we have been constructing one thing completely different — a prevention-first operation that may detect and cease fraud earlier than the verify cleared, not try and claw again misplaced funds years later.
Skeptics had cause to doubt. Authorities businesses announce transformations on a regular basis. The outcomes often don’t comply with.
So listed here are the numbers:
In fiscal yr 2025, Medicare financial savings from the prevention of fraud, waste and abuse hit $42 billion — an virtually 60% improve over the prior yr and the very best determine ever recorded in this system’s historical past. That’s not only a line on a spreadsheet. In Medicare’s coffers, $42 billion will pay for 3 million knee replacements, 7 million cataract removals or 37.5 million routine colonoscopies.
Discovering and stopping fraud will be costly, however return on funding additionally hit an all-time excessive — greater than $22 saved for each greenback spent on program integrity.
And right here’s the stat we’re proudest of: Practically 70% of these financial savings got here not from recovering cash already out the door, however from prevention-first actions — revoking fraudulent suppliers earlier than they may proceed billing, stopping improper claims on the level of submission and intercepting funds by way of prepayment controls earlier than they ever cleared.
We promised large modifications. The scoreboard says the Facilities for Medicare and Medicaid Companies delivered.
One key to success has been to lastly acknowledge the size of the issue and adapt appropriately. Healthcare fraud spreads like wildfire. Left unchecked, a single dangerous actor can turn out to be a community, a community can turn out to be an trade, and billions of taxpayer {dollars} can go up in smoke.
Many of those schemes are run by organized legal enterprises that rotate billing addresses, shuffle possession constructions throughout state strains and exploit federal applications with the operational sophistication of a profitable enterprise. They’re quick. They’re coordinated. And for years, they understood precisely how slowly authorities moved.
It was time to replace ways and take again the initiative. No extra chasing smoke after the flames have unfold. That meant monitoring the healthcare ecosystem, figuring out vulnerabilities and conducting “managed burns” to get rid of the situations that allow fraud to leap from one group, supplier or program to the subsequent. This shut scams down early, earlier than they turned huge and expensive.
The Facilities for Medicare and Medicaid Companies now sees networks, not simply claims. By integrating enrollment data, billing histories and utilization patterns throughout applications concurrently, we will determine coordinated fraud schemes — not remoted anomalies — in time to cease fee. That isn’t an incremental enchancment. It’s a completely different type of enforcement fully.
When our information signaled systemic abuse within the dwelling well being and hospice sector, we didn’t open a sequence of haphazard particular person audits. We started a coordinated nationwide crackdown, imposing a nationwide enrollment moratorium and suspending 808 suppliers. In California alone, suspended suppliers had billed $1.4 billion in 2025. And when these suppliers challenged the suspensions, investigations upheld 80% of selections — as a result of the enforcement was constructed on information, not guesswork.
Then there may be the motion that has no actual precedent on this program’s historical past: For the primary time, all 50 states have dedicated to coordinated Medicaid supplier revalidation — a simultaneous, nationwide reassessment of who ought to nonetheless be enrolled and billing. If we get this proper, then for the primary time in this system’s historical past, there will probably be nowhere for scammers to cover.
Early outcomes seem to bear that out: In Minnesota, for instance, greater than half of high-risk suppliers haven’t but handed revalidation. A decade in the past, that type of coordinated accountability throughout each state Medicaid program was merely not doable. Now it’s, and fraudsters are discovering that out.
The Facilities for Medicare and Medicaid Companies has additionally stepped up cooperation with legislation enforcement.
Multistate, multiprogram fraud schemes was practically unattainable to prosecute effectively as a result of the proof was scattered throughout jurisdictions. That’s modified due to cutting-edge information analytics and unprecedented cooperation that brings in state and federal legislation enforcement in addition to different businesses.
In 2025, the Facilities for Medicare and Medicaid Companies delivered 372 fraud referrals to federal legislation enforcement in circumstances masking $3.7 billion in billing. And after we say “referral,” we don’t imply a imprecise tip. We imply an organized, cross-referenced information file constructed to help prosecution. In April, such analytics helped the FBI’s Los Angeles subject workplace and First Assistant U.S. Atty. Invoice Essayli of the Central District of California convey prices towards eight folks accused of stealing greater than $50 million from Medicare.
The outcomes of this final yr have confirmed that authorities can transfer sooner than fraudsters, however one good season doesn’t imply we will sit again and watch dry underbrush pile up once more.
Staying one step forward of the fraudsters would require sustained funding within the information infrastructure, cross-agency partnerships and enforcement capability that make prevention doable. It’s going to require Congress to guard and construct on the analytical instruments that generated these report financial savings. And it’ll require each state Medicaid program to remain on the desk for the coordinated revalidation work that’s already rooting out dangerous actors nationwide.
We’ve constructed one thing that works — a transformative new anti-fraud technique that’s saved $42 billion for the sufferers who depend on Medicare and the taxpayers who fund it. The duty now’s to ensure it retains working.
Dr. Mehmet Oz is the administrator of the Facilities for Medicare and Medicaid Companies. Kim Brandt is the deputy administrator and chief working officer.
