CMS Fraud & Abuse Update: Areas of Focus in 2025

Author: Kaitlyn DelBene, Wachler & Associates, PC

October 2025

This year has seen a continued emphasis within the federal administration on identifying fraud within the Medicare and Medicaid programs. Increasingly, audit findings, as well as other investigatory efforts by CMS and federal partners, are leading to healthcare fraud investigations. This trend has picked up steam in recent months, and CMS has made various announcements telegraphing its efforts to combat fraud and abuse in federal healthcare programs. Providers should be aware of enforcement trends and consider seeking a legal or compliance review of their documentation and billing practices.

In June 2025, the Justice Department and Centers for Medicare & Medicaid Services announced the results of an effort dubbed the 2025 National Health Care Fraud Takedown, describing it as “an precedented effort to combat health care fraud schemes that exploit patients and taxpayers.” The June press releases emphasized the coordination among federal and state agencies and reported charges against 324 defendants, including 96 doctors, nurse practitioners, pharmacists, and other licensed medical professionals. Among the agencies that participated in the Takedown were the U.S. Attorneys’ Offices for the Eastern and Western Districts of Michigan, the Michigan State Attorney General’s Office, and the Michigan Medicaid Fraud Control Unit.

Certain areas of focus are apparent among the various healthcare fraud enforcement actions in 2025. Scrutiny continues for wound care services involving the application of amniotic allograft products, and wound care providers in this area should anticipate CMS post-payment audit requests and/or prepayment requests for additional documentation. Illegal diversion of prescription opioids also continues to be a focus, with involvement of the Drug Enforcement Administration. The Justice Department also identified telemedicine as a potential source of some fraud, including claims for genetic testing, durable medical equipment, and COVID-19 tests.

In addition to coordination among agencies, the federal administration is aiming to enhance its ability to identify potential healthcare fraud at the point of claim submission. According to the administration, ongoing enforcement efforts will utilize data analysis through cloud computing, artificial intelligence, and advanced analytics to “identify emerging health care fraud schemes.”

There is overlap between the areas targeted for enforcement actions and those receiving additional scrutiny under a new Innovation Center model announced by CMS in June, which will utilize a combination of artificial intelligence, machine learning, and clinician review to make prior authorization determinations for Original Medicare. The model, named the Wasteful and Inappropriate Service Reduction (WISeR) Model, is aimed at “protecting Medicare beneficiaries from being given unnecessary and often costly procedures.” Items and services subject to review include skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.

Currently, the WISeR Model is projected to be rolled out in six states not including Michigan, but providers should expect CMS’s efforts to expand in this area, as it prioritizes finding technology solutions for reducing spending on services it deems medically unnecessary or non-covered. CMS’s messaging around the WISeR Model also serves to further emphasize its focus on rooting out fraud: The model is meant to “streamline the review process for certain items and services that are vulnerable to fraud, waste and abuse.” Michigan providers of the services identified for review under the WISeR Model—which is slated to launch in January 2026—should also expect to see a continuing increase in post-service/pre-payment medical review by the Medicare Administrative Contractor. As audits increasingly lead to severe consequences in addition to overpayment determinations—from revocation of billing privileges to criminal investigations—it is more important than ever for providers to seek legal review to confirm that their claims to Medicare are compliant with coverage criteria and healthcare fraud and abuse laws.

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Short Bio: Katy DelBene is an attorney at Wachler & Associates, PC. Ms. DelBene practices in all areas of healthcare law, representing healthcare providers and suppliers in the defense of Medicare, Medicaid, and third-party payor audits, as well as a broad range of health professional and facility licensing and regulatory compliance matters.