As we look back on the first quarter of 2025, fraud, waste, and abuse (FWA) continue to pose serious challenges across the healthcare landscape. Bad actors are still relying on common schemes like kickbacks, false claims, and the exploitation of vulnerable patients to defraud health plans and deliver unnecessary—and often harmful—medical services. Here’s a snapshot of some of the most significant FWA cases reported from January through March 2025.
Unnecessary diagnostic scans and kickbacks: $70 million
Investigators are looking into a potential kickback scheme involving medically unnecessary brain scans that resulted in fraudulent Medicare claims. Federal documents state that the national sales director of a mobile diagnostics company allegedly conspired with others over seven years to offer illicit payments to physicians in exchange for ordering transcranial doppler ultrasounds. These payments were supposedly disguised through sham rental and administrative service agreements intended to mask the per-test compensation structure.
Durable medical equipment billing scheme: $30 million
An alleged Medicare fraud scheme involving durable medical equipment (DME) reportedly involved the use of telemarketing companies to generate DME orders by targeting Medicare beneficiaries. According to court documents, these orders were then billed to Medicare, despite being medically unnecessary or obtained without proper patient evaluations. Payments to marketing companies were allegedly made on a per-lead or per-order basis, violating the Anti-Kickback Statute.
Senior patient referral kickback scheme: $22 million
A former business owner is accused of exploiting elderly immigrants from the former Soviet Union by directing them to doctors who were willing to pay bribes for patient referrals. The fraud supposedly included billing Medicare for services that were either unnecessary or not provided at all. In addition to the fraudulent billing, officials believe the defendant laundered the illicit funds by paying family members in cash and transferring money to accounts in their names.
Pharmacy prescription kickback fraud: $20 million
A Philadelphia pharmacy is being charged for a Medicare and Medicaid fraud scheme dating back from 2016 to 2021. The operation reportedly submitted false claims for expensive medications, such as HIV treatments and the antipsychotic drug Latuda, which are known to generate high reimbursements from federal healthcare programs. Investigations suggest that the pharmacy paid customers to bring in prescriptions, which were then processed as if the medications were dispensed even though they were not.
Multi-payer billing fraud with false claims: $20 million
A Miami-based nurse practitioner and clinic owner is facing charges in connection with a healthcare fraud scheme while her former spouse has been charged with conspiracy to commit money laundering. From 2019 to early 2023, the practitioner allegedly conspired with others to submit fraudulent claims to Medicare, Medicaid, and private insurance companies for services that were never provided, including physical therapy and mental health treatments.
Unnecessary labor inductions and billing: $18.5 million
A hospital in Virginia is facing federal charges for its alleged role in a long-running healthcare fraud scheme involving a former physician. Prosecutors claim the hospital knowingly allowed a provider to induce early labor in pregnant patients, many of whom were on Medicaid, before they reached 39 weeks, often without medical necessity. The physician is believed to have falsified records to justify the procedures, and despite awareness of these practices, hospital staff continued to support and bill for them. The provider had a history of disciplinary issues and prior felony convictions but was still granted privileges at the facility.
Orthotic device billing fraud: $17 million
A licensed orthotics supplier has been arrested and charged in connection with an alleged multimillion-dollar healthcare fraud scheme involving medically unnecessary equipment. According to federal prosecutors, he ran multiple medical supply companies and was accused of buying doctors’ orders for orthotic braces that patients didn’t need. After being removed from the Medicare program, the scheme allegedly continued under a different company, where kickbacks were used to funnel fake prescriptions through marketing channels.
Nursing facility therapy billing fraud: $9 million
A Worcester skilled nursing facility is among nearly 20 locations in Massachusetts and Connecticut facing a federal lawsuit over an alleged widespread healthcare fraud scheme that spanned several years. Federal prosecutors say the facilities, under the leadership of their management company and therapy consultants, systematically overbilled Medicare and Medicaid by pushing patients into high-reimbursement therapy services that were medically unnecessary. Staff were reportedly pressured to document therapy sessions regardless of whether they occurred or were appropriate. Prosecutors say the scheme endangered vulnerable patients and drained public resources, as therapy services were sometimes painful or unwanted.
Lab testing and home health service fraud: $8 million
A Worcester-based lab and its owner are facing serious charges tied to an alleged multi-provider Medicaid fraud and kickback scheme that led to false claims submitted to MassHealth. Prosecutors claim that the lab submitted fake insurance claims for urine drug tests and home health services that were unnecessary, never provided, or not properly authorized. The scheme reportedly involved coordination with a home health agency and a physician, who allegedly approved services without actually treating or seeing patients.
Group home double billing and ownership fraud: $7.3 million
A Minnesota man has been charged for his alleged role in a Medicaid fraud scheme that authorities believe involved billing for services never provided, including personal care assistance at group homes and duplicate claims for clients at multiple locations. Despite being legally barred from operating a Medicaid-funded business due to a prior conviction, he allegedly concealed his ownership by using a family member’s name and forging documents.
Telemedicine cancer genetic testing scheme: $6.6 million
A Louisiana physician has been charged with conspiracy to commit healthcare fraud for authorizing cancer genetic tests for Medicare patients he never evaluated or treated. The charges claim he signed off on test orders through telemedicine companies in exchange for a flat fee per approval. Authorities say he falsely certified the tests as medically necessary despite never interacting with the patients.
How to evolve your FWA program in 2025 and beyond
Preventing inappropriate payments remains a top priority for health plans, but traditional methods of detecting healthcare FWA are no match for rapidly evolving schemes. Read our latest eBook to discover how advanced tools, machine learning, and a managed service model can take your approach to FWA prevention and management to the next level—protecting your program integrity and protecting your members from harmful schemes.
