09-07-2025
Four Things To Know About the Biggest Health Care Fraud in US History
Advocates for ideas and draws conclusions based on the interpretation of facts and data.
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The Department of Justice recently announced the largest health care fraud bust in U.S. history. After a two-year investigation dubbed "Operation Gold Rush" led by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), 19 people were charged with multiple crimes related to an alleged $10.6 billion Medicare fraud scheme.
The scale and complexity of the fraud are enormous. A foreign crime ring obtained stolen personal information of more than 1 million Americans, purchased dozens of U.S. health care supply companies, and then submitted fraudulent claims to Medicare for more than 1 billion urinary catheters and other supplies.
The U.S. Treasury Department and Inspector General Office are pictured.
The U.S. Treasury Department and Inspector General Office are pictured.
Getty Images
The good news is that Medicare and HHS OIG officials moved quickly to identify the fraudulent bills and stop payments before funds were dispersed, preventing more than 99 percent of the Medicare payments from reaching the alleged fraudsters. Although Medicare did pay a portion of the claims to the conspirators, government officials reportedly seized tens of millions of dollars of those ill-gotten gains. The bad news is that the perpetrators apparently collected about $1 billion from Medicare supplemental insurance companies.
Beyond the eye-popping scope of the scheme, Americans should pay attention to four important elements of this fraud scheme.
First, this operation illustrates the vital importance of having strong inspectors general (IG) protecting tax dollars. IGs, the internal watchdogs who root out fraud and waste in our federal government, have been under attack from the Trump administration, including the recent firing of 17 IGs (including me). As evidenced by Operation Gold Rush, IGs provide invaluable oversight to improve federal agencies and protect taxpayers' dollars. Every American should demand independent and effective IGs.
Second, this fraud scheme lays bare a long-standing need to strengthen Medicare data harvesting and analytics. When I was leading U.S. Senate investigations, our analysis revealed that Medicare paid hundreds of thousands of claims totaling $60 million to $100 million even though the prescribing doctor had died years earlier—five, 10, or even 15 years before the date of the prescription. Notably, our report and committee hearings occurred 17 years ago, flagging that HHS OIG identified similar problems seven years prior.
One of our 2008 investigations reviewed millions of Medicare claims and found highly questionable diagnoses and related medical equipment prescriptions. For example, we reviewed hundreds of thousands of claims paid by Medicare for blood test strips for diabetics, but we found diagnoses totally unrelated to diabetes—from the bubonic plague to tuberculous.
Our 2008 rudimentary data analytics revealed these anomalies, a figurative abacus compared to the sophisticated analytics technology OIGs and federal staff have nowadays. One hopeful sign: the Department of Justice (DOJ) announced the creation of a Health Care Fraud Data Fusion Center to facilitate agencies' use of cloud computing, artificial intelligence, and advanced analytics to share information, identify fraud schemes, and proactively prevent improper payments.
Third, Operation Gold Rush highlights how international fraud rings have infiltrated federal programs to steal personal information and American tax dollars. In this case, the criminals came from Estonia, Kazakhstan, and Russia. "A majority of the fraud," one HHS OIG official told The Washington Post, "occurred by individuals who never even set foot in the United States." IGs have identified foreign crime rings as a major problem in a variety of programs, such as unemployment insurance and pandemic benefits, for years.
Finally, this case relates to a "pay-and-chase" model. Typically, federal agencies pay claims quickly, then identify fraud and chase the fraudsters to recover ill-gotten money. Given the sophisticated games that criminals now play, especially in the international context, the pay-and-chase model is rarely effective in deterring fraud and recovering stolen money. By the time law enforcement discovers the fraud, the money is long gone.
Operation Gold Rush seems to represent a shift in how the federal government addresses fraud. The IG community has long urged agencies to shift from pay-and-chase to instead implementing anti-fraud measures before issuing payments. Agencies historically have put a thumb on the scale in favor of paying quickly, which raises fraud risks. With the advent of AI and sophisticated data analytics tools, the IG community and feds can do both: triage claims to prevent fraud and pay claims quickly.
All told, Operation Gold Rush shows inspectors general are on the frontlines of the fight against fraud to stay ahead of sophisticated international crime rings stealing our tax dollars. It is more urgent than ever that we have independent, experienced IGs in place to proactively fend of increasingly sophisticated criminal networks. Now is the time to properly fill open IG positions and invest in this crucial law enforcement resource to prevent the next gold rush.
Mark Lee Greenblatt is an expert on government ethics and compliance, an attorney, and author. Most recently, he served as inspector general for the U.S. Department of the Interior. From 2019 to 2025, Mr. Greenblatt led a team of nearly 300 investigators, auditors, and attorneys responsible for oversight of more than 70,000 agency employees.
The views expressed in this article are the writer's own.
