When Healing Becomes a Business of Betrayal -By Fransiscus Nanga Roka

The United States’ campaign against healthcare fraud should be applauded. However, it raises a troubling issue: why is a system designed to protect vulnerable individuals such a lucrative business for criminals?

On June 23, 2026, the United States Department of Justice made public that they had filed charges against a total of 455 individuals (of which 90 were licensed health care providers) who allegedly engaged in fraudulent activities which resulted in fraudulent claims totaling approximately $6.5 billion. The charges were brought across 56 federal judicial districts, and in addition to those districts, there were also cases brought in 45 states and territories. Additionally, there were 50 state Medicaid fraud control units that assisted in the investigation. It is important to note that the charges are only allegations, and therefore do not imply that any defendant has been found guilty. Furthermore, “false claims” do not equate to actual financial loss.

However, the accusations reveal a much more troubling issue than creative bookkeeping using clinical expertise to extract money.

A case in Texas involves allegations that a nurse practitioner billed Medicare over $1 million each year (on average) for wound grafts that were not medically necessary. Authorities have confiscated several high-end luxury items from the nurse practitioner, such as a necklace worth approximately $865,000. Another case involves allegations that a doctor approved 63 cardiac images in less than 11 seconds. The student athlete then died.

The wound of a patient must not be used for marketing purposes. Cardiac screening must not be used solely as an opportunity to generate revenue through billing without regard to professional assessment. When medical procedures are reimbursed prior to receiving formal evaluation, exploitation has developed a method of operation.

The main problem with this policy is that there is a large amount of time that elapses after someone files a claim for health insurance benefits before they are able to verify that the care was provided. Criminal prosecution may help to hold individuals accountable for their past misbehavior, but it will not provide retroactive treatment to an individual, prevent unnecessary medical procedures, nor will it return a lost life.

Authorities have stated that they have taken control of more than $182 million. CMS (Centers for Medicare & Medicaid Services) suspended 1,079 providers, and revoked the billing rights of 1,403 providers. Additionally, DOJ (Department of Justice) announced plans to expand its analytical/AI capabilities. While these actions are significant, administrative exclusions are not license revocations for physicians, and seizures do not represent total restitution.

Washington must evaluate its effectiveness based on more than just the amount of attention drawn to successful prosecutions. Rather, it should assess how well it has prevented false statements from being made, how effectively it protects and recovers funds for victims of crime, and how much money is returned to those who have suffered financial losses.

First, make changes to the reimbursement process when the high cost of wound products creates a very strong incentive to use these products. To ensure that only patients that actually require the use of high-cost wound products receive them, we should have a process in place that requires documentation of the clinical reasons why the products are being used, proof of how much they cost to acquire, and independent reviews of the use of these products based upon the amount of risk involved with using them. It will be important to maintain the ability to provide timely access to care for patients who truly require the use of high-cost wound products.

Second, link the claim reviews to clinical data. When there is a high number of claims that are difficult to complete, duplicate services being provided, and payment amounts for hospitalizations that do not match the hospital records, these should be investigated. Automated triggers should only be used as a beginning: human review of claims will still be necessary for both patients and providers, explanation of why a decision was negative and an accelerated appeal process.

Third, accountability needs to be traced throughout the whole business process. To do this, investigators need to consider the manufacturer(s), marketer(s), executive(s), as well as any beneficial owner(s) in addition to clinical personnel. Accountability must based upon the level of participation and knowledge, and not just based on someone’s position within their profession.

Fourth, create a link between the process of recovering from a breach and the repair of damage caused by the breach. Develop clear pathways for patient restitution, correcting care and notifying all patients who were impacted. Enhance the protections provided to whistleblowers, and provide funding to support independent help for those whose identity or health records were compromised.

In addition to all of the above, we need to increase international cooperation regarding evidence, asset tracing, and returning fugitives through legally permissible means. Criminals use technology to move money at a rate far greater than individual jurisdictions can respond. Therefore, we must work together to find ways to reduce this time lag while still respecting due process.

After an amazing blow-out, there is a tendency for politicians to claim success. What is much more difficult, however, is to take apart the reasons why the next blowout will occur.

A healthcare organization has failed on multiple levels when a patient’s pain can be treated as an asset (inventory) and the relationship between a provider and patient (professional trust) is damaged. The U.S. needs to pursue all forms of proven fraud vigorously—and reform its payment systems so that providing care for patients will be more profitable than exploiting them.

Fransiscus Nanga Roka

Faculty of Law University 17 August 1945 Surabaya and Managing partner Law Firm Victorious Indonesia