ROOTING OUT FRAUD, WASTE, AND ABUSE IN MEDICARE
Alternative Care Organizations Identify and Stop Medicare Fraud in Its Tracks
Accountable care organizations routinely review claims data to understand how best to meet their patients’ need and identify potential suspicious or fraudulent activity. This work is critical for protecting taxpayers from unnecessary spending and helping promote Medicare solvency. Read more about how Village Medical uses data to prevent, identify and stop fraud.
Village Medical's story:
Village Medical, a national network of primary care clinics, has a dedicated team of actuarial scientists who mine data from more than 600 practices to root out and stop fraud, waste, and abuse. Through this practice, the Village Medical team has identified $6.2 million in suspect claims from the first half of 2025, plus more than $5 million in newly identified suspect claims from 2024.
The suspect claims in 2025 show emerging trends in potential durable medical equipment (DME) fraud. For example, DME claims from the Phoenix area increased from $30 per-member per-month (PMPM) in 2024 to more than $100 PMPM in the first quarter of 2025. Additionally, there are increasingly long lags between the service date and paid date compared with the company’s baseline metrics.
Only six providers accounted for the suspect claims across 18 markets. To stem the cycle of fraud, suspected cases were shared with regional clinical teams. Clinical teams coordinated chart reviews and contacted patients to see if they had received medical equipment. Many times, patients reported back they had not received or requested the equipment. Suspected claims were then submitted to the Centers for Medicare & Medicaid Services (CMS) for further investigation.
From 2024 through July 2025, a total of 3,816 suspected DME claims have been submitted to CMS for investigation, representing 27% of claims investigated by the Village Medical team.
By focusing on patient outcomes and quality of care, value-based care models allow organizations like Village Medical to identify and address waste, fraud, and abuse. Without continued support for value-based care, organizations like Village Medical might not get the support they need.
This patient story has been de-identified to protect patient privacy consistent with HIPAA – no real patient names are referenced, while the experience described reflects actual events.