Several years ago, our fraud investigators started noticing an unusual trend. More and more claims for urinary catheters, knee braces and other durable medical equipment were coming in from out-of-network suppliers. The company names seemed odd, and they were often in obscure locations. And when we checked with members to ask about the equipment, they all told us the same thing: I never ordered that. Our fraud investigators partnered with law enforcement. In 2025, the Justice Department announced Operation Gold Rush, which produced the largest loss amount ever charged in a U.S. healthcare fraud case. While that justice was indeed victory, healthcare fraud is ever increasing. “What we continue to see nationally is these schemes are just getting bigger,” Kurt Spear, our vice president of FIPR, said. “They’re more complex, more sophisticated. They’re better financially backed as well.” Read more about how our fraud teams are fighting on behalf of members: https://lnkd.in/giHjUBgU
Adam Wilson
1w
My old colleagues in PI had coined the phrase "the mummy fraud scheme" tied to fraudulent DME claims for members years ago. Where did the "Gold Rush" name for this come from?
Sherri Davis
17h
Keep up the great work.
jeff leston
1w
and Operation Gold Rush was entirely preventable.
jeff leston
1w
How much did Highmark rebate to your ERISA customers?
You are a "Rockstar" Kurt Spear!
Congratulations Kurt Spear CFE, CISSP !!
Congats Kurt and an amazing result.Unfortunately it's a never ending battle and why, what your team is doing, is so important.
Manoj Kapoor
1w
Congratulations Kurt Spear CFE, CISSP to you and your team. Outstanding work!
Congratulations to you and the team on such a huge achievement! Our Fraud, Waste, and Abuse Department plays such a critical role in the company to be able to accomplish victories like this and keep going!
Phantom DME companies were one of the most prevalent types of medicare and medicaid fraud I encountered at Optum Avoidance Investigation Unit. However with tenacity and due diligence a memorable case scheme was identified as a RICO style organized actor operation that created multiple out of state complete individual small business filings, CMS registrations and fake address of operations. My inquiry of the client’s main database located over 30 phantom DME false operations that had already penetrated the payment integrity system. What is more troubling is the actors were tied to a middle east off- shore operation that had access to medicare/medicaid member information and actually made calls to the patient to secure DME approval for braces, wheel chairs, crutches, walkers, orthopedic shoes etc. Most members never received DME, but some actually received counterfeit products worth pennies on the federal dollar with no medical benefits.