DOJ-OIG TARGETING MEDICARE SPENDING AND PROVIDERS
Chronic Care Management Services
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chartspan: Patient Care Management Services (An example) 
Better patient care. More practice revenue.
- Chronic Care
- Advanced Primary Care
- Annual Wellness Visits
HHS-OIG Audit of Medicare Payments for Chronic Care Management Services at Risk of Noncompliance,
03/16/2026
Chronic Care Management (CCM) is the coordination of care for patients with two or more chronic conditions expected to last at least 12 months or until death, placing them at significant risk of serious health issues.
- Starting January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) began reimbursing Medicare providers for CCM services under the Medicare Physician Fee Schedule for eligible patients. From 2019 to 2024, Medicare Part B payments for these services have significantly increased.
- We will examine Medicare Part B payments for CCM services that may be at risk of noncompliance with Medicare’s requirements for multiple chronic conditions.
- This may result in more audit requests, overpayment determinations, payment suspensions, and investigations by HHS-OIG and DOJ. Office of Audit Services In-Progress
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Genetic Testing
Genetic and non-genetic tests. We analyzed key metrics for genetic and non-genetic procedure codes. Genetic test codes were identified using a list developed by the U.S. Department of Justice and updated by OIG, which includes tests for both pathogens and humans. Non-genetic tests were selected from the fee schedule that did not involve genetic material. Using Part B claims data, we examined trends in Medicare spending, utilization, payments per enrollee, and laboratory payments exceeding $1 million from 2018 to 2024. Due to a revised methodology for identifying genetic tests, our trends may differ from those in previous OIG reports.
- We identified the 25 lab test procedure codes with the highest Medicare Part B spending in 2024. For each code, we calculated the percentage changes in spending and utilization from 2023 to 2024, as well as the median amount paid per test in 2024.
OIG Work Related to Lab Testing
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Wound Care Fraud / Skin Substitute: nurse.org
DOJ Cracks Down on Wound Care Fraud as Skin Substitute Cases Surge to $10 BILLION
Written By: Chaunie Brusie, BSN, RN, March 19, 2026
Two owners of a Phoenix wound care company conspired to have “sales representatives” order unnecessary skin graft replacements for Medicare patients, resulting in one owner receiving over $279 million in illegal kickbacks.
The Centers for Medicare and Medicaid Services (CMS) indicated in October 2025 that increased scrutiny of the skin-care product industry is due to potential fraud involving high-profit items that often go unnoticed. They reported that prices can exceed $2,000 per square centimeter and estimated a $19.6 billion reduction in 2026 spending on skin substitute services.
**Implications for Nurses and Providers**
- Nurses may not see an immediate impact from the Department of Justice’s crackdown on wound care fraud, but they may observe stricter documentation efforts regarding wound care processes. Possible changes include:
– Increased oversight of treatment decisions
– Greater focus on documenting medical necessities
– Enhanced training in compliance and reporting
Some wound care providers are concerned that these crackdowns could negatively affect patients who genuinely need these products.
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Medicare Advantage
Aetna Agrees to Pay $117.7 Million to Resolve False Claims Act Allegations
March 11, 2026
Aetna Inc., a Pennsylvania-based insurer, will pay $117.7 million to settle allegations of violating the False Claims Act by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees. The claims relate to erroneous codes for morbid obesity from 2018 to 2023, resulting in inflated Medicare payments. Aetna submitted codes for individuals whose Body Mass Index (BMI) did not support those diagnoses, resulting in misleading reimbursements.
- This civil settlement resolves a lawsuit under the whistleblower provisions of the False Claims Act, which allows private individuals to sue for false claims against the government. The case, titled United States ex rel. Mary Melette Thomas v. Aetna Inc., et al., is in the U.S. District Court for the Eastern District of Pennsylvania. The whistleblower, a former Aetna risk-adjustment coding auditor, will receive $2,012,500 from the settlement.
- The outcome was the result of a coordinated effort by the Justice Department’s Civil Division, the U.S. Attorney’s Office for the Eastern District of Pennsylvania, and the HHS Office of Inspector General (HHS-OIG).