The federal government could potentially save billions if Congress takes actions the Office of Inspector General (OIG) has recommended in recent reports.
Indeed, lawmakers could potentially save $17 billion if they follow up on the recommendations the OIG has made in recent reports to improve Health and Human Services programs. The reports recommend legislative actions, as well as program or process changes that Congress can address.
The savings include:
- Nearly $7 billion by improving risk adjustment in Medicare Advantage. The potential savings are based on investigations into the questionable use of health risk assessments and chart reviews in Medicare Advantage.
- Roughly $5 billion by ensuring inpatient hospital stays are appropriately billed.
- Approximately $3 billion by improving the oversight of hospital billing under “two-midnights” policy.
- $1.3 billion by paying provider-based facilities at the Medicare freestanding, non-facility rate.
- $1 billion by preventing duplicate Medicaid managed care enrollments.
Gilead Sciences agrees to $202M settlement over kickbacks to docs
The United States has settled a civil fraud lawsuit against Gilead Sciences, Inc., a large pharmaceutical manufacturer, that develops, manufactures, and sells drugs for the treatment of infectious diseases, including HIV/AIDS.
The settlement resolves claims that Gilead offered and paid kickbacks in the form of honoraria payments, meals, and travel expenses to health care practitioners who spoke at or attended Gilead speaker events to persuade them to prescribe HIV drugs manufactured by Gilead in violation of the anti-kickback statute and Gilead to submit false claims to the federal government for the HIV drugs in violation of the False Claims Act.
Under the settlement, Gilead agreed to pay $202 million, the majority of which will be paid to the federal government and the remainder to various states. As part of the settlement, Gilead also made extensive factual admissions regarding its conduct.
Leader of multi-million dollar fraud scheme sentenced to 14 months in prison
Manishkumar Patel, 44, of Pelham Manor, N.Y., who last year pled guilty in connection with a $48 million health care fraud and kickback scheme involving the sale of fraudulent prescriptions for durable medical equipment, has been sentenced to 14 months in prison.
“As he previously admitted, Manishkumar Patel bilked Medicare for nearly $50 million,” said Jay Clayton, the United States Attorney for the Southern District of New York, in the announcement. “Frauds on our Medicare system increase costs for all Americans, and worse yet, potentially restrict access to those in need of critical healthcare. Patel’s 14 month sentence in federal prison sends an important deterrent message to those who would seek to bilk our Medicare system.”
According to court documents, between 2019 and 2022, Patel fraudulently sold prescriptions and doctors’ orders for durable medical equipment, pharmaceuticals, and laboratory tests to durable medical equipment suppliers, pharmacies, and laboratories. He obtained the scripts from call centers that called Medicare beneficiaries and asked them perfunctory questions designed to justify a script that would be reimbursed by Medicare. He turned the information from those calls into scripts by, variously: arranging cursory telemedicine appointments with the beneficiaries; a practice called “doctor chasing,” in which the information was sent to a doctor who signed the script without seeing the patient and who was frequently unaware of what they were signing; and obtaining forged scripts. Patel then sold the scripts to Medicare providers, who filled the orders and billed Medicare.
Because the scripts were fraudulently obtained, many beneficiaries rejected the items and many doctors threatened to report Patel for fraud, and Medicare frequently refused to pay for the scripts.
In addition to the prison term, Patel was sentenced to one year of home detention. He was also ordered to pay $48 million to the Centers for Medicare & Medicaid Services and to forfeit $6 million.
Nurse practitioner convicted of $2M Medicare fraud
A federal jury has convicted a Louisiana nurse practitioner for her role in an over $2 million health care fraud scheme.
Shanone Chatman-Ashley, 45, of Opelousas, La., was a nurse practitioner and enrolled as a provider with Medicare. She worked as an independent contractor for companies that allegedly provided telehealth services to Medicare beneficiaries. As part of the scheme, she routinely ordered knee braces, suspension sleeves, and other types of durable medical equipment for patients who had not been examined by her or another medical provider. She concealed the scheme by signing documentation falsely certifying that she had consulted with the beneficiaries and personally conducted assessments of them.
According to the court documents, from 2017 to 2019, Chatman-Ashley signed more than 1,000 orders for medically unnecessary equipment, causing over $2 million in fraudulent Medicare claims and over $1 million in reimbursements. In exchange for the orders, Chatman-Ashley received kickbacks and bribes from the telehealth services companies.
“Illegal kickback payments undermine and corrupt the medical decision-making process,” said Special Agent in Charge Jason E. Meadows of the U.S. Department of Health and Human Services (HHS) OIG in the announcement. “Both the payer and recipient of kickbacks benefit from these schemes, but it’s ultimately the taxpayers who foot the bill. HHS-OIG will continue collaborating with law enforcement and prosecutors to protect the Medicare trust fund that millions of Americans depend on.”
Chatman-Ashley was convicted of five counts of health care fraud. She is scheduled to be sentenced on July 31 and faces a maximum penalty of 10 years in prison on each count.
California man sentenced in connection with $17M Medicare fraud scheme
A California man was sentenced to 12 years in prison and three years of supervised release for his role in a years-long scheme to defraud Medicare of more than $17 million through sham hospice companies and his home health care company.
Petros Fichidzhyan, 44, of Granada Hills, schemed to bill Medicare for hospice services that were not medically necessary and never provided. Fichidzhyan and his co-schemers controlled hospice entities and used foreign nationals’ personal identifying information (PII) to conceal the scheme, using the PII to, open bank accounts, submit information to Medicare, and sign property leases. He also misappropriated the names and PII of several doctors, two of whom were deceased, to fraudulently bill Medicare for purported hospice services. As a result, Medicare paid the sham hospices nearly $16 million. Fichidzhyan received nearly $7 million, with more than $5.3 million laundered through a dozen shell and third-party bank accounts.
He also obtained more than $1 million in false claims paid to his home health care agency, which fraudulently used a doctor’s name and identifying information as having certified Medicare beneficiaries for home health care. When the doctor confronted Fichidzhyan about the fraud, Fichidzhyan attempted to cover up the scheme by paying the doctor $11,000.
Fichidzhyan pleaded guilty to health care fraud, aggravated identity theft, and money laundering in February 2025. At sentencing, he was also ordered to pay $17 million restitution, and the court preliminarily ordered the forfeiture of a home bought with fraudulent proceeds. The government has also seized nearly $3 million from bank accounts associated with the fraud.