The 2025 NHCAA Annual Training Conference, held Nov. 18-21, featured discussions around the use of AI in investigations, how bad actors are leveraging the technology, common durable medical equipment fraud schemes and Affordable Care Act enrollment fraud.
AI has been a major trend in AI this year, NHCAA CEO Lou Saccoccio said, and it featured heavily in sessions at the ATC in terms of its impact on health care fraud investigations and how bad actors are using the technology.
Saccoccio shared other highlights from the conference, as well as NHCAA’s focus for 2026.
How was the annual training conference? Could you share a few highlights from it?
The conference went very well. We did have a little challenge in the sense that the government shutdown precluded our federal attendees from attending. But other than that, it went really well, and we were able to have them present via Zoom, so most of the sessions were covered that did have presenters from the federal government.
One of our highlights was the keynote speaker Kim Brandt from CMS, who gave us a good overview of what’s happening at CMS now [and] some of their priorities, the biggest being to “crush fraud,” which is a phrase that they use now. Dr. Oz is administrator of CMS; that’s one of his priorities. That was a highlight.
The general session that we had was the panel of federal and state folks that are very key to fighting fraud. We had the deputy inspector general at HHS for investigations speak. We had the head of the health care fraud unit at FBI speak. We had somebody from the Justice Department and someone from a state Medicaid fraud control unit. That went over very well. They’re talking about the successes they had, their priorities into the future and some of the challenges that they face.
And then another highlight I think was a general session we had on artificial intelligence, which is a big issue for everybody, but it’s certainly in the fraud space – whether AI can be used to commit fraud, which it certainly can with all sorts of ways to imitate individuals’ voices and medical records and even X-rays and those kinds of things – but also the opportunities of using AI to detect and prevent fraud. So that was kind of a theme that ran through the conference as well – the impact that artificial intelligence is going to have on health care fraud.
There were a lot of sessions touching on AI and fraud. How would you say that investigators are using AI to detect and prevent fraud?
Well, it’s still at the beginning, very early in the process as to how they may use it to prevent fraud. Obviously, applying AI to claims data and trying to, again, find the outliers, but even doing that, you’re still going to have to do an investigation, so there’s no magic bullet. But certainly, it can help set priorities and maybe prevent some fraud in the sense that you could stop payment on some things before payment goes out, or put those claims coming in under a more strenuous review process that seem like they’re outliers, which can help prevent fraud.
And then there’s some administrative things. Say, hotline calls are coming in alleging that there’s been some fraud committed. AI can play a role in going through those calls and other leads that you may have. I think it’s still very early in the process as to how it may be used to help and to detect and prevent fraud
You mentioned that bad actors are using AI to manipulate their voices. Are there any other tactics that they’re using to try to avoid detection? And are those tactics complicating investigations for investigators?
They’re starting to complicate investigations. As I mentioned, medical records is a big issue – generating false medical records, copy and paste, those kinds of things, so that if they turn over medical records they may look like actual medical records.
Folks focused on committing fraud could also use AI to try to find the vulnerabilities in the payers’ rules to try to find out what can work and what may not work. I think even for them it’s a new process, as well, so it’ll be who gets ahead of the curve on artificial intelligence with respect to the health care front.
Other sessions were looking at fraud around Affordable Care Act enrollments, which I thought was a particularly pertinent session given that it’s open enrollment now. Can you talk about that?
One of the big issues with ACA enrollments are brokers and people signing folks up from different states to try to bring in the money for signing those folks up. So that’s a known issue, and AI could help with that by identifying the individuals that are being enrolled.
There’s also fraud around folks claiming limited income to be eligible for the subsidies when maybe they’re not really eligible for those. That’s more of a government issue because the government’s paying the subsidies.
So whenever you have large sets of data like that, AI could play a role in trying to discern what’s real and what’s not, or at least give the folks investigating a head start to know where to look and what other investigations to do.
There’s been talk in Washington recently about fraud related to the subsidies. Do you think there’s anything at the policy level that could help prevent enrollment fraud? Anything that the federal government can do?
I know there’s some discussion in Congress about perhaps extending the enhanced subsidies that were in effect during COVID, but in doing that, also limiting the folks that are eligible for it by income. So if your income’s over a certain level, should there really be any subsidies, or should there really be any enhanced subsidies? So I think that’s coming into play in any discussions that may take place in Congress regarding extension of those subsidies.
And then to prevent fraud, I guess doing a better job of verifying eligibility. Whether it’s Medicaid, whether it’s subsidies, there are rules, and are the rules being applied? And how much effort are you putting into trying to really verify the eligibility of these individuals? Are you just taking at face value what they tell you, or are you doing some checking? Obviously, that could be a very intense and expensive process in itself, so you have to find the happy medium between extensive checking and making the program work for the people that it’s supposed to work for.
More broadly, what have been the biggest trends in health care fraud this year?
First, of course, is going to be AI. We put together an AI working group, and based on that work group, we did an issue brief about the use of generative AI in health care fraud. So that was a big piece of it for us. As far as general fraud in health care, durable medical equipment is still an issue. It’s always been an issue and will continue to be an issue.
Earlier in the year and late last year there was the issue with catheters – folks being contacted by telephone and providing information and then doctors signing off on DME that was not necessary, and they never saw the patients. So telemarketing fraud is big.
Another issue that’s coming into play, I think, is behavioral health care fraud. A lot of [behavioral health care] is done virtually, which is fine and is important, but that lends itself to fraud. … Remote patient monitoring is another issue that’s coming to the fore. … I read something today where the former director of the CDC – she was only in that position for a short time – but she believes that as we go down the road here, about 90% of health care will be delivered at home rather than in hospitals.
Again, because you’re using technology, there’s always a chance for fraud to be committed. Whenever there’s an advance of some type, there are going to be folks that find a way to use it to find the vulnerabilities in that advance to commit fraud. So those are some of the things, but all sorts of areas: laboratory testing – you could go down the list – opioid issues with pill mills, physicians writing prescriptions basically for cash, that kind of thing. Although I think the federal government’s done a really good job, both federal and state governments, on really making a dent in that issue.
Looking forward to next year, what will be NHCAA’s focus?
For us, we need to really focus on the education and training side. A big issue for us is going to be a new education platform that we put in place just two years ago, but it’s starting to grow: NHCAA Learn. We’re trying to make sure that we’re growing the number of on-demand courses we have on that learning management system and opening that up as we have done to our members, basically as a member benefit. [We’re] also trying to do some subscriptions with the government so that on a yearly basis they pay a certain amount and then all the folks – say the FBI, HHS OIG – have access to that.
We have a a number of courses available on on the site now, but one of our main goals over the next year is to grow the library of courses that are available and really make that a key tool for our members, both our commercial side members and our government partners, to have a learning platform that that is useful to them and provides what they need as far as training their folks.