Final 12 months, we wrote within the Los Angeles Occasions that the Facilities for Medicare and Medicaid Companies was finished chasing criminals after we’d already handed them cash. We stated we have been constructing one thing totally different — a prevention-first operation that will detect and cease fraud earlier than the test cleared, not try and claw again misplaced funds years later.
Skeptics had purpose to doubt. Authorities companies announce transformations on a regular basis. The outcomes normally don’t observe.
So listed below are the numbers:
In fiscal 12 months 2025, Medicare financial savings from the prevention of fraud, waste and abuse hit $42 billion — an virtually 60% improve over the prior 12 months 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 might 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: Almost 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 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 dimensions of the issue and adapt appropriately. Healthcare fraud spreads like wildfire. Left unchecked, a single dangerous actor can change into a community, a community can change into 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 techniques 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 following. This shut scams down early, earlier than they grew to become 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 are able to determine coordinated fraud schemes — not remoted anomalies — in time to cease fee. That’s not an incremental enchancment. It’s a totally different type of enforcement totally.
When our knowledge signaled systemic abuse within the house 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 choices — as a result of the enforcement was constructed on knowledge, 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 likely 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 attainable. Now it’s, and fraudsters are discovering that out.
The Facilities for Medicare and Medicaid Companies has additionally stepped up cooperation with regulation enforcement.
Multistate, multiprogram fraud schemes was once practically unattainable to prosecute effectively as a result of the proof was scattered throughout jurisdictions. That’s modified due to cutting-edge knowledge analytics and unprecedented cooperation that brings in state and federal regulation enforcement in addition to different companies.
In 2025, the Facilities for Medicare and Medicaid Companies delivered 372 fraud referrals to federal regulation enforcement in instances overlaying $3.7 billion in billing. And after we say “referral,” we don’t imply a imprecise tip. We imply an organized, cross-referenced knowledge file constructed to assist prosecution. In April, such analytics helped the FBI’s Los Angeles area workplace and First Assistant U.S. Atty. Invoice Essayli of the Central District of California carry prices in opposition to eight folks accused of stealing greater than $50 million from Medicare.
The outcomes of this final 12 months have confirmed that authorities can transfer quicker than fraudsters, however one good season doesn’t imply we are able to sit again and watch dry underbrush pile up once more.
Staying one step forward of the fraudsters would require sustained funding within the knowledge infrastructure, cross-agency partnerships and enforcement capability that make prevention attainable. It’s going to require Congress to guard and construct on the analytical instruments that generated these file 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 verify 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.
