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Healthcare Fraud: A Persistent Problem, Not a New Crisis

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  Published in Politics and Government on Thursday, February 12th 2026 at 13:06 GMT by Forbes
      Locales: UNITED STATES, UNITED KINGDOM

The Enduring Shadow of Fraud: Beyond EVV and Towards Proactive Healthcare Integrity

Recent news cycles often portray healthcare fraud as a newly emergent crisis, a consequence of pandemic-era loopholes or rapidly evolving digital payment systems. However, this narrative is fundamentally misleading. Healthcare fraud is not a recent phenomenon. It's a decades-old problem, consistently adapting and becoming more complex, and the current focus on specific systems like Electronic Visit Verification (EVV) risks obscuring the larger, persistent challenge.

For years, fraudulent activities have plagued the healthcare industry, costing taxpayers billions annually and, more importantly, compromising patient care. The methods employed are diverse, ranging from billing for services never rendered - a particularly prevalent issue in home healthcare, the initial impetus for EVV - to upcoding (billing for more expensive services than provided), unbundling (billing separately for services that should be bundled together), and outright identity theft. What has changed is the sophistication of these schemes, fueled by advancements in technology and the increasing digitization of healthcare records and financial transactions.

The introduction of Electronic Visit Verification (EVV) systems was, at its core, a logical response to widespread fraud within home healthcare. These systems aim to confirm that a caregiver actually visited a patient and delivered the services billed to insurance programs. By utilizing technologies like geolocation and biometric identification, EVV sought to create an auditable trail, reducing the opportunity for phantom billing. The principle is simple: verify service delivery before payment. Yet, the rollout of EVV has been fraught with difficulties, hampered by political resistance, bureaucratic delays, and implementation challenges.

The politicization of EVV highlights a critical flaw in our approach to healthcare integrity. A solution designed to protect both taxpayers and patients became entangled in partisan disagreements and special interests. This demonstrates how easily even well-intentioned initiatives can be derailed when they clash with established power structures or entrenched business practices. The focus shifted from the problem EVV intended to solve - fraud - to debates about cost, implementation timelines, and perceived burdens on providers.

However, framing the debate solely around EVV is a mistake. EVV is merely one tool in a much larger arsenal needed to combat healthcare fraud. Relying on reactive measures--investigating and prosecuting fraud after it occurs--is akin to bailing water from a sinking ship with a teaspoon. We need to shift our focus towards proactive strategies that anticipate and prevent fraud before it takes root. This requires a multi-pronged approach centered around leveraging the very technologies that fraudsters are exploiting.

Building a Proactive Defense:

• Artificial Intelligence and Machine Learning: AI/ML algorithms can analyze vast datasets of claims data to identify patterns indicative of fraudulent activity. These algorithms can flag suspicious claims for review, prioritize audits, and even predict future fraud attempts. The ability to identify anomalies in billing practices, provider behavior, and patient demographics is invaluable.
• Blockchain Technology: Blockchain offers the potential to create a secure, transparent, and immutable record of healthcare transactions. This can significantly reduce the risk of data manipulation and fraud by providing a verifiable audit trail. While still in its early stages of adoption, blockchain holds promise for improving data integrity and preventing fraudulent claims.
• Advanced Data Analytics: Investment in robust data analytics capabilities is essential. Beyond basic fraud detection, sophisticated analytics can identify emerging fraud schemes, track the flow of funds, and assess the effectiveness of fraud prevention measures. Real-time monitoring of claims data is crucial.
• Enhanced Collaboration & Information Sharing: Siloed data and a lack of communication between healthcare providers, payers, and law enforcement agencies hinder fraud detection and prevention efforts. Establishing secure platforms for information sharing and fostering greater collaboration is vital. This requires overcoming legal and regulatory barriers that currently restrict the exchange of information.
• Transparency & Standardized Billing: Lack of transparency in billing practices makes it difficult to identify and investigate fraudulent claims. Standardizing billing codes and promoting clear, accessible billing information for patients can deter fraud and empower consumers to detect errors.

Combating healthcare fraud is not a one-time fix but an ongoing commitment. It requires a fundamental shift in mindset, moving beyond reactive measures and embracing a proactive, technologically driven approach. The goal isn't simply to punish fraudsters, but to build a healthcare system founded on trust, integrity, and - most importantly - the delivery of quality care to those who need it.