AI Is Changing The Health Care Fraud Fight
Presented By Delaware Senior Medicare Patrol
The enormous size and scope of the U.S. health care system make it an attractive target for fraudulent activity. So far in 2025, the Department of Justice has already uncovered tens of billions of dollars’ worth of fraudulent activity related to health care.
The unique vulnerabilities of older adults, including their high use of medical services, cognitive decline, and lack of technological literacy, make this demographic a prime target for health care fraudsters.
The elderly are specifically targeted in such types of fraud involving Medicare, the Department of Veterans Affairs, hospice and nursing home care, home health services, durable medical equipment, and telemedicine.
What are common health care fraud schemes?
Health care fraud schemes are multifaceted. In past fraud cases, patterns include phantom billing for visits and procedures that never happened, upcoding for more expensive services than were actually provided, charging for unnecessary medical procedures and therapies, getting illegal kickbacks and false referrals (where health care providers profit from unnecessary tests or prescriptions), misrepresenting a health care provider or health insurance company to receive information or funds illegally, and obtaining and using someone’s Medicare number to file fraudulent claims via identify theft.
How does AI affect health care fraud?
On the one hand, AI has given fraudsters new tools. With the help of AI, scammers can now impersonate Medicare representatives and health care providers by generating very realistic robocalls, deepfakes, and cloned voices, and by creating fake documents, websites, and personalized phishing/spoofing emails that appear sophisticated, legitimate, and trustworthy.
Therefore, seniors are often confronted with schemes that feel authentic and are hard to detect. Even careful victims can be deceived when a voice on the line sounds familiar or when an email includes accurate personal details scraped from public sources. To make things worse, these AI-driven schemes are automated and replicated at large scale, expanding their reach and impact on victims.
Fortunately, AI is not just helping fraudsters but investigators, too, and can be part of the solution:
- Pattern recognition algorithms can be used by Medicare and insurers to flag suspicious billing patterns across large numbers of claims in just seconds.
- Natural-language processing (NLP) tools that analyze text can scan provider notes for inconsistencies or medical codes that do not match diagnoses.
- Predictive analytics can help investigators focus on the highest-risk providers and reduce investigation time.
- AI-enhanced monitoring systems can cross-reference data from pharmacies, clinics, and laboratories to identify duplicate or conflicting claims.
- AI prompts can be used to identify if emails, phone numbers, or websites are suspicious.
What can seniors do to protect against health care fraud?
Seniors can stay safer by combining awareness with proactive steps:
- Review your Medicare Summary Notice (MSN), explanation of benefits, and online claims at MyMedicare.gov.
- Be vigilant and stay informed about the different, evolving types of health care scams and red flags.
- Beware of “too good to be true” or “free” offers for genetic tests or medical devices requiring insurance details, especially if the offer is conveying a sense of urgency.
- Hang up on unsolicited calls and never click on links or open attachments in uninvited emails or texts.
- Verify before you trust: If someone calls from Medicare, your pharmacy, or your doctor’s office, look up the official contact number online and call back.
- In unsolicited emails, hover your mouse over the sender’s address. If it looks odd or mismatched, it is likely fake.
- Use strong passwords and two-factor authentication for medical portals and accounts.
- Do not give out any personal information, such as Medicare, Social Security, or insurance numbers or financial information over the phone unless you initiate the contact.
- Guard your Medicare number as carefully as a credit card.
- If you are not sure if a call, text, email, or ad is legitimate, talk to a trusted friend, family member, or your financial services professional before you share any information.
- If you use an AI tool, never enter any personal information into the prompt.
Report suspicious activity to 1-800-MEDICARE or the Delaware Senior Medicare Patrol (1-800-223-9074), The bottom line is AI can make health care fraud schemes feel more authentic and harder to detect, but it can also empower consumers and regulators to detect fraud faster. My advice: Combine tech-savvy habits with your old-fashioned skepticism to protect your health, finances, and peace of mind.
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