RISE National 2026 kicked off Tuesday with a blockbuster lineup of keynote speakers from the Centers for Medicare and Medicaid Innovation, United States Department of Justice, and the Department of Health and Human Services Office of Inspector General. They offered a clear look at the forces reshaping Medicare, Medicare Advantage, and health care oversight. Here are the highlights from their sessions..
CMMI Director Abe Sutton outlines push toward affordability in Medicare Advantage and Original Medicare
The conference opened with a fireside chat featuring Abe Sutton, director of the Center for Medicare and Medicaid Innovation (CMMI) and deputy administrator at CMS, who joined virtually, and moderator Shannon Decker, Ph.D., MBA, M.Ed., founder and CEO of VBC One. Sutton framed Medicare as being at a “pivotal moment,” with affordability and clinical value set to drive the next phase of transformation across both Medicare Advantage and Original Medicare.
While “Medicare Advantage played a good role in making care more affordable for people,” he said there is more work to be done. Sutton pointed to a recent report that found a senior couple who are aging into Medicare now need more than $400,000 in savings to feel secure in covering health costs under traditional Medicare, which is roughly double what’s required under Medicare Advantage.
He outlined three pillars guiding the Innovation Center’s work: evidence based prevention, empowering beneficiaries, and boosting competition in concentrated health care markets—including leveling the playing field for independent practices and improving consumer choice.
Looking ahead to 2026–2028, Sutton said CMS is preparing major policy and payment shifts designed to encourage earlier clinical engagement with beneficiaries and reward true improvements in care delivery. That includes leveraging emerging technologies, such as biotech to AI—not just to optimize revenue but to materially reduce costs and expand access.
Sutton highlighted the forthcoming ACCESS model, which launches this summer and pays technology companies based on outcomes for conditions such as metabolic disease, musculosketal, and behavioral health. The model represents a rapid-cycle shift in CMS strategy, conceived and implemented in under a year. He also pointed to the LEAD model, which will take effect in 2027, that aims to offer hospitals decade-long financial benchmarks if they move aggressively away from fee-for-service and toward accountable, outcome based care.
Asked whether these initiatives are signals or immediate marching orders for health plans and providers, Sutton said the changes are active, accelerating, and designed to push the industry “further and faster” than CMS alone can move. He also believes it would be better for the industry to “refocus excellence away from risk adjustment and toward clinical care.”
He emphasized that while voluntary models remain the norm, mandatory models will continue when necessary to generate valid data or prevent risk selection—reflecting lessons learned from previous iterations such as the REACH model. Sutton also devoted significant time to the role of data liquidity and artificial intelligence (AI) in the next stage of care delivery. He described a future where real time information sharing, interoperability, and AI enabled clinical augmentation sharply reduce friction for both patients and providers. CMS’ ACCESS model is the first to require participants to push clinical data directly to providers via APIs, rather than waiting for providers to request it.
Despite the magnitude of change underway, Sutton closed on an optimistic note, saying advances in accountable care, prevention, cell and gene therapy, and AI powered clinical tools give him confidence that the health care system is on the verge of meaningfully expanding Americans’ health span while lowering long term costs.
DOJ’s Edward Crooke: FCA enforcement reaches record high and MA is a top target
Next, Edward C. Crooke, assistant director of the Civil Division’s Fraud Section at the U.S. Department of Justice (DOJ), warned federal enforcement has reached unprecedented levels—and that Medicare Advantage (MA) and managed care organizations remain squarely in the government’s crosshairs.
Crooke, a 20 year DOJ veteran who oversees civil fraud investigations, told attendees that in 2025 the federal government secured $6.8 billion in False Claims Act (FCA) settlements and judgments, including $5.7 billion from health care cases alone, marking a record year for enforcement. Whistleblower activity has also surged, with 1,298 qui tam actions filed in 2025, translating into roughly 12 new cases per attorney in the civil fraud section.
MA is now DOJ’s top priority
Crooke emphasized that MA has become DOJ’s “number one” enforcement priority, driven by growing concerns around risk adjustment fraud, network adequacy, and access to care.
One reason that MA has become a frequent target is due to risk adjustment fraud, he said, noting that Medicare pays MA plans based on diagnoses and diagnoses patterns have changed dramatically over the past 15 years.
He cited multiple recent, high‑profile cases:
- Kaiser Permanente paid $556 million to resolve allegations that the organization conducted retrospective reviews of patient history and were identifying diagnoses and then pressuring their employed physicians to add those diagnoses not considered during patient visits, even up to a year later. The government alleged that the organization knew about the conduct and ignored the red flags, including concerns raised by their own physicians and the results of audits by their own compliance office.
- Aetna paid $117 million following allegations that it added diagnosis codes identified via retrospective chart reviews but failed to delete unsupported ones—practices Crooke said is sometimes described as “one‑way” chart reviews. Crooke doesn’t like the term because it suggests the problems are with submissions of diagnoses codes not the failure to delete unsupported ones. He stressed that if you have information about invalid diagnosis codes, you are obligated to act on the information.
- DOJ also continues active litigation against UnitedHealth Group and Elevance over similar allegations involving MA risk scores.
- The government has also expanded its focus to downstream entities, including risk‑bearing provider groups and vendors. Crooke highlighted a $62 million settlement with Seoul Medical Group, which allegedly submitted invalid diagnoses and involved liability not only for the organization but also its former president and a medical imaging partner.
- Another case, involving Independent Health, included claims that the plan and its vendor DxID added diagnosis codes not supported by the medical record, sometimes inferred from algorithms or prior‑year data. The DOJ eventually secured a $98 million settlement.
Kickbacks: A growing enforcement area
Crooke warned that DOJ and HHS‑OIG are increasingly scrutinizing kickbacks in the MA industry—whether from plans to provider groups, providers to brokers, or MA organizations to brokers.
A 2024 fraud alert from OIG detailed improper incentives across the industry, prompting renewed enforcement. Recent examples include Oak Street Health’s $60 million resolution over alleged payments to brokers to steer beneficiaries into specific plans, and multiple settlements for plans that provided gift cards as incentives to administrative staff for each beneficiary enrolled.
Compliance: Fix problems early
Crooke urged organizations to self‑disclose issues early, warning that emails saying “let’s not put that in writing” often become key evidence of knowing violations.
Both OIG and CMS maintain formal self‑disclosure protocols, and DOJ allows cooperation credit that can significantly reduce penalties and damages, sometimes down to single damages. But cooperation, he stressed, must extend beyond subpoena compliance, and include proactively identifying, quantifying, and explaining the misconduct.
Crooke closed by acknowledging that his daily exposure to fraud skews his view of the health care system, but he emphasized that the intent of enforcement is not to punish success but to protect federal programs and promote integrity. “You can go out in the world and do good things and make money,” he told attendees. “And that should be rewarded.”
HHS OIG’s Arjuna Swaminathan warns about AI-driven fraud
In the closing keynote, Arjuna Swaminathan, chief artificial intelligence officer at the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), described an alarming escalation of health care fraud that uses AI to fabricate patient identities, generate believable clinical documentation, and even clone the voices of seniors.
“We collectively, as a health care ecosystem are no longer just fighting sloppy billing and upcoding. We are fighting industrialized deception,” he warned, introducing what he calls the “ghost ecosystem,” a network of fake digital identities engineered to mimic real patients and providers.
Criminal organizations now submit billions of dollars in fraudulent claims using stolen data, ghost patients, and “audit‑perfect” AI‑generated clinical notes. “They create unique, medically plausible, sophisticated clinical notes… for patients they've never seen,” Swaminathan explained.
Equally alarming is the rise of AI-driven voice cloning: “Fraudsters are creating fake recordings of seniors consenting to expensive genetic testing or durable medical equipment… You’ll hear a deep fake that sounds exactly like a 70‑year‑old grandmother.”
Fraud is ‘statistically indistinguishable from the truth’
Legacy fraud systems, built on rules and flags, cannot keep pace with actors now armed with the same advanced tools as investigators.
“In 2026, fraud isn’t just fake—it’s statistically indistinguishable from the truth,” Swaminathan said, emphasizing how criminals have learned to “turn everything green” within payer systems designed to detect anomalies.
This new scale and speed of fraud requires that organizations move beyond isolated claim analysis to holistic, relationship-based insight, he said. Graph neural networks, for example, can map hidden ties among providers, pharmacists, and ghost patients—a “digital spider web” where disturbance on one strand signals a broader scheme.
AI defense requires human oversight
Swaminathan urged organizations not just to react to fraud, but to “flip the script” by using AI for autonomous prepayment verification, identification of impossible clinical journeys, and detection of linguistic markers that signal elevated risk.
But he also stressed that AI without humans is dangerous. “AI solutions without human oversight are just a faster way to make mistakes,” he said.
Among the major risks:
- The defensibility gap: When payers can’t explain why AI flagged a claim, they risk litigation and due-process challenges.
- Algorithmic bias: Models trained on historically biased data can learn how to “automate the prejudice,” disproportionately flagging providers in underserved communities.
- Adaptive fraudsters: Criminals probe AI defenses just as cybersecurity actors probe networks, exploiting blind spots.
To overcome these risks, Swaminathan introduced the concept of an integrity loop, a closed‑loop system where AI provides speed and scale, while humans provide context, ethics, and intent determination. “AI can flag patterns, but you, with your functional knowledge and your human judgment, determine intent,” he emphasized. “You provide the clinical context and ethical stewardship that no algorithm can replicate. The golden result is the integrity loop when the power of AI meets the wisdom of humanity.”
This partnership aims to shift the industry from a reactive “pay and chase” model to a proactive, sustainable approach to fraud prevention.
AI will elevate health care careers, not replace experts
Addressing fears that AI will replace jobs, Swaminathan told the audience that human roles will become more—not less—essential. “Experts who understand the domain and how to leverage AI are indispensable,” he said. “This is not a dying skill… These are skills that are essential to the future of health care.”
AI will take on massive pattern-recognition tasks, he noted, freeing human workers to focus on complexity, nuance, and member-centered decision-making.
Swaminathan closed with a challenge for health care leaders to actively shape how AI is implemented within their organizations. “The question is not whether AI will transform health care integrity—it will… The question is, will you choose to guide that transformation with your wisdom?”