When most people hear the word fraud in healthcare, they probably picture something fairly obvious. A provider bills for a service they never performed. Someone submits a claim for a patient they never treated. An organization knowingly receives money for something it never provided. Those situations certainly happen. Healthcare fraud can involve intentional misrepresentation of services, medical necessity, billing, or other information in exchange for financial gain.

Enforcement priorities can change quickly, making it increasingly important to understand, and document, the legal and reimbursement basis for decisions when they are made.

The proposed 2027 Home Health Prospective Payment System rule suggests health agencies may receive an estimated 2.4% payment increase—approximately $420 million—while Medicare beneficiaries would continue to receive expanded access to care at home.

Healthcare organizations often have established relationships between Legal and Compliance. Over time, teams develop processes, policies, and working relationships that help everyone understand where their responsibilities begin and end. The challenge comes when something new enters the picture.

Medical billing and coding requires healthcare organizations to pay attention to details that can change over time, across payers, and even based on where a patient receives care. A code that worked correctly for a claim last month may create a problem today because a health plan changed how it interprets that code or requires additional information. Telehealth Shows How Quickly Requirements Can Change Telehealth provides a good example. During the early stages of COVID-19, t

What makes CRUSH particularly interesting is the breadth of who and what it could impact. This isn't just about DME fraud. The ideas CMS is considering potentially touch hospitals, laboratories, Medicare Advantage and Part D plans, Medicaid and CHIP, DMEPOS suppliers, provider enrollment, billing, AI, payment suspensions, ownership disclosure, beneficiary solicitation and more.

This White Paper suggests enrollment information, ownership records, physician orders, proof of delivery, medical necessity documentation, beneficiary information, and billing patterns are likely to receive increasing attention.

Federal agencies are investing heavily in real-time analytics and cross-agency data sharing. Compliance programs that rely exclusively on retrospective audits and documentation reviews risk missing the very patterns regulators are now designed to detect.

Private equity and other forms of outside investment have become an increasingly visible part of healthcare. Investment can bring capital, infrastructure, technology, and opportunities for growth, but it also creates compliance considerations that healthcare organizations need to address directly.

As healthcare continues its shift toward value-based care, providers need partners who can help both the technical and regulatory sides of quality reporting. Learn about why I partner with Comprise Health to navigate both the technical and regulatory side of quality reporting.

This case is not simply about controlled substances. It is about governance. An effective compliance program is not measured by the number of policies it maintains or the sophistication of its hotline. It is measured by what leadership does when uncomfortable information arrives.

The Methodist settlement serves as a sobering reminder that EMTALA compliance is no longer judged solely by what happens in the treatment room. It is judged by the entire patient journey from the moment the individual arrives at the emergency department doors.

Healthcare organizations often enter new Medicaid initiatives with a strong understanding of regulatory requirements. The reality is that California healthcare compliance also depends on whether your operational model can consistently deliver the services those regulations are designed to support.

At first glance, the proposed 2027 Home Health Prospective Payment System rule appears to be a routine update. But buried within the proposed rule is something far more significant. Read more to understand the compliance implications.

Provider directories are no longer simply member-facing tools. They are increasingly being viewed as evidence of network adequacy, access to care, and organizational accountability.

The recent $30 million settlement involving Advanced Pathology Solutions (APS) is being reported as another kickback case. While that's true, focusing only on the Anti-Kickback Statute misses the bigger compliance lesson.

An important reminder that clinical judgement cannot be delegated, automated, or subordinated to business objectives.

A small hospital demonstrated that effective cybersecurity is achievable when organizations focus on prevention, detection, and response as part of their operational culture.

The future of healthcare enforcement is increasingly data-driven. OIG is no longer looking for a needle in a haystack. Analytics helps them identify the haystack before they ever ask for the needle. The organizations best positioned for the future will be those that review their data with the same level of scrutiny as the government.

Interest in GLP-1 medications has grown rapidly, and with that growth has come an increase in organizations offering prescriptions through online platforms. GLP-1 telehealth has created new opportunities for patients to access care, particularly for those who face transportation barriers or limited provider availability. The reality is that convenience should never come at the expense of patient safety, regulatory compliance, or sound clinical judgment.