From Firefighting to Control: How Federal Action Is Reshaping Fraud, Waste, and Abuse in Healthcare

Fraud and waste are estimated to account for 25% of total U.S. healthcare spending. In response, federal efforts to address fraud, waste, and abuse (FWA) in healthcare are accelerating. Over the past year, enforcement actions have targeted high-risk areas, including durable medical equipment, catheter-related billing schemes, and skin substitutes. More recent initiatives, such as CMS’ CRUSH program, reflect a more coordinated, intensified push to identify and eliminate wasteful spending across the system.

These actions rely on increased use of advanced analytics, expanded oversight and accountability, and earlier detection and intervention. For healthcare organizations, this evolving landscape introduces new challenges. While enforcement is focused on bad actors, it may increase scrutiny, documentation requirements, and payment delays more broadly. At the same time, there is growing uncertainty around how FWA-related costs and interventions may influence performance benchmarks, financial reconciliation, and risk-based payment models.

This session will examine the implications of inappropriate spending and FWA enforcement for risk-bearing providers and health plans operating in value-based care (VBC) environments. Drawing on recent enforcement patterns and historical fraud cases, we will explore where risks are emerging, how they scale, and why traditional detection approaches are no longer sufficient. The session will introduce a “preventive forensics” framework to help organizations identify outlier trends earlier and align with federal response to suspected FWA.  
 

What You'll Learn:

1. Explain how recent federal enforcement actions and initiatives, including CRUSH, reflect a more intensive and coordinated approach to fraud prevention
2. Identify emerging patterns and drivers of fraud, waste, and abuse, including technology-enabled coding practices and novel technology and services billing, and analyze the potential disruption these practices pose to VBC success.  
3. Describe how to apply a “preventive forensics” approach to detect potential fraud earlier and assess potential impacts on financial performance
    

Speakers: