The Trump administration has been slamming the doors on rampant fraud in the Medicare system. These fraudsters have ripped off the taxpayers to the tune of billions of dollars, but the tide is starting to turn.
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On Thursday, Dr. Mehmet Oz, the administrator of the Centers for Medicare & Medicaid Services (CMS), and Kimberly Brandt, Deputy Administrator & Chief Operating Officer of CMS, took to the pages of the Los Angeles Times to count coup on some recent busts, including how much money is involved – and these were some pretty impressive numbers.
In fiscal year 2025, Medicare savings from the prevention of fraud, waste and abuse hit $42 billion — an almost 60% increase over the prior year and the highest figure ever recorded in the program’s history. That’s not just a line on a spreadsheet. In Medicare’s coffers, $42 billion can pay for 3 million knee replacements, 7 million cataract removals or 37.5 million routine colonoscopies.
Finding and stopping fraud can be expensive, but return on investment also hit an all-time high — more than $22 saved for every dollar spent on program integrity.
And here’s the stat we’re proudest of: Nearly 70% of those savings came not from recovering money already out the door, but from prevention-first actions — revoking fraudulent providers before they could continue billing, stopping improper claims at the point of submission and intercepting payments through prepayment controls before they ever cleared.
We promised big changes. The scoreboard says the Centers for Medicare and Medicaid Services delivered.
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Here’s the key: Understanding the scope of the problem:
One key to success has been to finally acknowledge the scale of the problem and adapt appropriately. Healthcare fraud spreads like wildfire. Left unchecked, a single bad actor can become a network, a network can become an industry, and billions of taxpayer dollars can go up in smoke.
Many of these schemes are run by organized criminal enterprises that rotate billing addresses, shuffle ownership structures across state lines and exploit federal programs with the operational sophistication of a successful business. They are fast. They are coordinated. And for years, they understood exactly how slowly government moved.
That’s simultaneously reassuring and worrisome. Reassuring that they are getting a handle on how big the problem really is, and worrisome because of how big the problem really is.
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In my previous career, as I’ve mentioned in the past, I was a jacket-and-tie corporate guy, and I made a pretty good career of my expertise in Corrective and Preventive Action (CAPA) systems and root cause analysis, which I spent almost 20 years as an independent consultant, teaching the staffs of big corporations how to use. CAPA is a problem-solving tool, and the first step in solving a problem lies in determining scope; in other words, getting your arms around the problem and determining how big it really is. CMS would appear to be well on the way to doing just that, where Medicare fraud is concerned.
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But what about all the other fraud out there? What about fraud in the Supplemental Nutrition Assistance Program (SNAP)? What about fraud in things ranging from daycare to hospice care centers? What about all that?
The trillion-dollar federal budget seems to be a smorgasbord for fraudsters. Dr. Oz would seem to have done some great work on getting a grip on the Medicare side. But if there’s one thing that’s apparent in all this, it is that there is much, much more work to be done. And the other thing that’s apparent is that Democrats will resist, every step of the way.
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