The highest fraud schemes of 2025

All through 2025, federal and state authorities uncovered schemes involving every little thing from pointless lab assessments to fraudulent telehealth companies and hospice care. These instances spotlight the evolving techniques dangerous actors use to take advantage of vulnerabilities—and the pressing want for payers to remain vigilant. Whereas the strategies differ, the aim is similar: revenue on the expense of sufferers and payers.

In our newest version of FWA Insights, we break down three main classes of FWA—lab testing, dwelling Health and hospice, and telehealth—with real-world examples from 2025 and suggestions for mitigating these dangers.

FWA in lab testing

Lab testing fraud stays one of the crucial pervasive types of healthcare fraud, largely due to the excessive reimbursement charges for sure assessments and the convenience of exploiting billing codes. Unhealthy actors usually goal assessments like urine drug screens and respiratory pathogen panels, submitting claims for companies that had been by no means carried out or had been medically pointless. These schemes ceaselessly contain kickbacks, falsified documentation, and coordination amongst a number of entities, together with labs, physicians, and generally dwelling Health companies. The monetary affect is staggering, with some instances reaching lots of of tens of millions of {dollars}, and the ripple impact consists of elevated premiums and lowered belief in authentic suppliers.

Listed here are three main examples from 2025:

• $500M COVID-19 testing scheme: Two individuals billed Medicare, Medicaid, TRICARE, and personal insurers for COVID-19 tests that were never conducted, utilizing affected person insurance coverage knowledge collected beneath the guise of “free” testing.

• $15M respiratory pathogen panel fraud: A South Carolina man allegedly billed Medicare for unnecessary respiratory pathogen panel tests, lots of which had been by no means ordered by a doctor—and a few for sufferers who had already died.

• $12M hospital lab fraud: Texas hospital executives submitted false claims for urine drug tests, claiming sufferers had been handled of their services when no such companies occurred.

Health plans can cut back lab testing fraud publicity by verifying legitimate CLIA certification, monitoring for outlier billing patterns, and flagging unimaginable day situations or weekend testing that defy operational norms. As well as, knowledge mining for suppliers billing each presumptive and definitive assessments on the identical date—or utilizing a single definitive code for all sufferers—can uncover improper practices. These steps assist guarantee testing aligns with Facilities for Medicare & Medicaid Providers (CMS) and CLIA rules and is medically mandatory, defending plans from inappropriate claims.

Dwelling Health and hospice fraud

Dwelling Health and hospice applications are designed to offer compassionate look after weak populations, however they’ve turn into prime targets for fraud. These schemes usually contain enrolling sufferers who don’t meet eligibility standards, billing for services never rendered, or inflating the extent of care supplied. Suppliers partaking in these practices exploit the complexity of rules and the problem of verifying companies delivered in dwelling settings. Past monetary losses, these schemes can hurt sufferers by diverting assets away from authentic care and eroding belief in vital applications.

FWA schemes in dwelling Health and hospice care are rising extra refined, requiring payers to strengthen detection capabilities. Integrating superior Technology—corresponding to machine studying—into each prepay and postpay options, mixed with human experience, permits proactive identification of suspicious patterns earlier than claims are paid. This strategy not solely helps forestall and handle fraud but in addition reduces the burden on particular investigations items, making certain assets are used effectively whereas safeguarding plan integrity.

Telehealth fraud

Telehealth has dramatically improved entry to care, however its fast enlargement has additionally created new opportunities for fraud. Frequent schemes embrace billing for companies not rendered, approving pointless assessments, and leveraging telemarketing to generate fraudulent claims. Unhealthy actors usually exploit relaxed rules launched in the course of the COVID-19 pandemic, in addition to the problem of verifying digital encounters. These schemes not solely drain healthcare assets but in addition undermine confidence in telehealth as a authentic care supply mannequin.

• $6.6M most cancers genetic testing scheme: A Louisiana doctor allegedly Health-care-fraud” goal=”_blank” rel=”noopener”>authorised genetic assessments for Medicare sufferers through telemedicine with out ever evaluating them, receiving kickbacks for approval.
• $2.7M telehealth genetic testing fraud: A UK citizen allegedly ran a telemedicine firm that submitted false Medicare claims for genetic tests, receiving over $600,000 in reimbursements.
• $11K psychotherapy fraud: A Miami psychotherapist, beforehand convicted of a $70M fraud, billed Medicaid for telehealth sessions regardless of being barred from federal applications.

Whereas latest audio-only coding updates present an added safeguard, Health plans should stay vigilant towards improper telehealth billing. Guaranteeing correct documentation, together with the proper place of service, is vital to forestall overbilling, underbilling, or unimaginable day situations. Plans must also overview all 2025 CPT and HCPCS code updates and ensure that medical information totally assist billed companies. As a result of telehealth documentation can contain nuanced particulars that Technology alone might miss, thorough audits and cautious scrutiny are important to mitigate FWA danger.

Cotiviti’s suggestions for mitigating FWA

To successfully fight fraud, waste, and abuse, payers should take a proactive, data-driven strategy. Superior analytics and predictive modeling enable organizations to determine anomalies in billing patterns and flag high-risk suppliers earlier than fraudulent claims are paid. Shifting past retrospective audits, built-in cost integrity applications allow prepayment interventions that catch errors early, decreasing administrative burden and stopping improper funds earlier than they happen.

Equally necessary is a holistic view of knowledge and powerful collaboration with suppliers. Cross-channel monitoring—combining claims, scientific, and telehealth knowledge—helps uncover patterns that span a number of service varieties, strengthening detection capabilities. On the similar time, educating suppliers on compliance necessities and finest practices fosters transparency and reduces inadvertent errors. Collectively, these methods empower payers to remain forward of evolving fraud schemes and shield each monetary assets and affected person care.