Federal authorities allege in a criminal complaint that a durable medical equipment company in Florida and another in Texas charged Medicare for more than 1.6 million orthotic braces, catheters, wound dressings and other items that were not needed, resulting in $3.3 billion in charges, nearly $1.8 billion of which was paid before payments were suspended. Nika Machutadze, a Russian citizen living in Austin, Texas, was charged with conspiracy to commit money laundering in connection with the scheme.

Former physician Don Wagoner of Kokomo, Ind., and the now-shuttered Wagoner Medical Center have agreed to pay nearly $1.7 million to settle allegations of Medicaid fraud. Prosecutors say Wagoner submitted more than 5,000 fraudulent claims from 2011 to 2013 for extensive urine tests. Wagoner surrendered his medical licenses after being convicted on felony charges related to opioid prescriptions.

Joel Rufus French, a former college football All-American, has been convicted for his role in a $200 million health care fraud scheme that targeted Medicare and the Department of Veterans Affairs' civilian health program. The scheme, which garnered nearly $200 million through fraudulent billing, involved altering recordings and paying telemedicine companies for fake medical orders. French owned multiple medical equipment companies involved in these fraudulent activities and worked with overseas call centers that pressured Medicare beneficiaries into providing insurance information, according to prosecutors.

Eleven people, including six who worked for the Virgin Islands Department of Human Services, entered not guilty pleas in a $309,000 Medicaid fraud case. The defendants are accused of bypassing eligibility safeguards in government computer systems, resulting in improper disbursement of Medicaid funds.

The National Institutes of Health Information Technology Acquisition and Assessment Center has announced it is canceling its $50 billion CIO-SP4 IT services contract. The CIO-SP4 contract faced numerous challenges, including over 350 protests and delays due to changes in proposal requests. With the cancellation, NITAAC will extend the previous CIO-SP3 contract until next year.

Alaffia Health raised $55 million in a Series B investment round to support commercialization of an agentic AI platform for health care claim reviews. The platform extracts and analyzes clinical data from medical records and clinical documentation to ensure claims are consistent with health plan policies and guidelines. The tool is designed to assist clinicians reviewing claims.

Blue Shield of California is working to improve its prior authorization process by digitizing medical policies and integrating AI. The health plan has developed a centralized medical policy repository and partnered with Salesforce to create an interoperability hub, and it is working to automate more processes while ensuring that AI is not used to deny, delay or modify care, in compliance with state law.

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