Five Critical Themes in Healthcare FWA: Insights from Jessica Gay's Testimony
Five Critical Themes in Healthcare FWA
Insights from Jessica Gay’s Testimony
A LUCKY MOMENT FOR INTEGRITY ADVANTAGE 🍀
March is a month inspired by luck and opportunity, and we are still energized by a moment that made us feel truly fortunate. On February 3rd, 2026, our very own Jessica Gay, Vice President and Cofounder of Integrity Advantage, testified before the House Committee on Energy & Commerce, Subcommittee on Oversight and Investigations.
The hearing, ‘Common Schemes, Real Harm: Examining Fraud in Medicare and Medicaid,’ explored the very real impact that fraud, waste, and abuse (FWA) have across our healthcare system. As an organization, we couldn’t be prouder, that Jessica was chosen to share her 15 years of experience and insight on such a national stage.
Full Hearing Video: ‘Common Schemes, Real Harm: Examining Fraud in Medicare and Medicaid’
Catch Jessica’s full testimony and every exchange with the Subcommittee.
Watch the complete video here!
THE HEART OF THE MATTER: FIVE KEY INSIGHTS
In her testimony, Jessica summarized the realities facing today’s Medicare and Medicaid environments, focusing on five central themes:
Size and Scope of Healthcare FWA
Victims of Healthcare FWA
Coverage Benefits and Schemes in Medicaid and Medicare
Challenges Across the Industry
Considerations for Change
Below is a summarized look at each focus area from her remarks.
THEME #1: SIZE & SCOPE OF HEALTHCARE FWA
Jessica began by outlining the sheer scale of fraud, waste, and abuse. Industry estimates place FWA between 3% and 10% of all U.S. healthcare spending, meaning anywhere from $159 billion to over $500 billion is lost each year. With national healthcare expenditures reaching $5.3 trillion in 2024, even conservative estimates are staggering.
The financial cost is only part of the problem: FWA affects patients, providers, programs, and ultimately the integrity of our entire system.
THEME #2: VICTIMS OF HEALTHCARE FWA
A central message in Jessica’s testimony was clear: everyone is impacted. Patients face unnecessary or unsafe services, reduced access to legitimate care, and rising costs. Fraudulent treatments, excessive procedures, or services billed but never provided can lead to medical risks that are both real and lasting.
Ethical providers are affected, too. When bad actors exploit the system for profit, public trust erodes, making it harder for honest clinicians to deliver appropriate care.
Taxpayers feel the burden. With federal programs like Medicare, Medicaid, CHIP, and ACA subsidies accounting for $1.7 trillion, nearly a quarter of the federal budget, any diversion of funds toward fraudulent activity harms the entire nation.
THEME #3: COVERAGE BENEFITS & SCHEMES IN MEDICAID AND MEDICARE
Jessica summarized several areas where concerning patterns of FWA continue to surface. These examples represent only a portion of the schemes we encounter across the plans we support, but they illustrate the scope of the issue.
Applied Behavioral Analysis (ABA)
Widely used to support children with autism spectrum disorder, ABA has become a frequent target for misuse. Common issues include inadequate documentation, cloned or inconsistent records, poor oversight, and billing that does not align with services provided.
NonEmergency Medical Transportation (NEMT)
Designed to remove transportation barriers, NEMT fraud often includes billing for trips that never occurred (trips to nowhere), inflated mileage, upcoding, or charging for cancelled appointments.
Home and Community Based Services (HCBS)
Fraud can include services provided by non-credentialed individuals, lack of physician oversight, excessive or inappropriate hours billed, falsified authorization numbers, and documentation that doesn’t match actual care.
Laboratory Services
High volume lab testing remains vulnerable to misuse. Trends include unnecessary genetic panels, telemarketing driven enrollments, missing orders or results, unbundling, duplicate billing, and services billed but never rendered.
Skin Substitutes & DME
These high-cost items are often misused through excessive quantities, unnecessary applications, or billing for products never provided. Durable Medical Equipment (DME) faces similar issues, including items never supplied, upcoding, and products pushed through aggressive telemarketing rather than legitimate medical need.
We’ve released a 9-part series on our YouTube channel featuring Jessica’s full testimony and every question she addressed during the hearing.
Click here to watch the series!
THEME #4: CHALLENGES ACROSS THE INDUSTRY
Jessica also spoke to the broader structural barriers that make preventing FWA difficult. Medicare and Medicaid process massive volumes of claims, and while prompt pay rules ensure providers are reimbursed quickly, they limit how much verification can be done upfront.
Medicaid adds another layer of complexity. Each state operates differently, and when policies, responsibilities, and expectations vary, or remain unclear, fraudsters exploit the gaps. Many Program Integrity Units face resource shortages, outdated systems, or fragmented oversight that slow their ability to respond.
Across the country, common challenges include:
Insufficient or inconsistent policy guidance
Under resourced investigative and program integrity teams
Fragmented responsibilities between states and MCOs
Imbalances across people, process, and technology
Difficulty quantifying the value of prevention
These gaps make it harder to detect fraud, and easier for it to flourish.
THEME #5: CONSIDERATIONS FOR CHANGE
To address these vulnerabilities, Jessica offered several recommendations aimed at strengthening oversight and improving program integrity.
She emphasized the need for clearer and more consistent policies, especially in areas where states have limited guidance. Training and awareness must also increase, ensuring investigators, analysts, and leadership understand emerging schemes and their operational impacts.
Jessica also called for stronger collaboration and data sharing across state and federal agencies, MCOs, and commercial payers. Breaking down silos is essential for detecting multiprogram fraud.
Additionally, she underscored the importance of balanced investment in people, processes, and technology, along with modernization of credentialing and monitoring systems. More integrated data platforms, combining NPI information, sanctions, billing histories, and other key indicators, would significantly strengthen early detection and response.
CLOSING THOUGHTS
As we reflect on Jessica’s testimony, we are reminded of how fortunate we are to have a leader who can articulate the real challenges facing healthcare programs and the real opportunities for change. In a month that celebrates luck, it feels fitting to acknowledge how lucky we are that Jessica’s expertise, integrity, and passion are helping shape national conversations.
Her testimony reinforces why our work matters and why continued vigilance, collaboration, and innovation are essential. Jessica brought a powerful voice to this hearing, one that represents not just our organization, but the patients, providers, and communities who depend on a strong and honest healthcare system.
While luck may have opened the door, it’s our team’s commitment and integrity that will keep driving this mission forward. 🍀
INTEGRITY ADVANTAGE IS HERE TO HELP
Whether it’s conducting FWA program assessments, strengthening internal processes, or providing outsourced SIU support, Integrity Advantage partners with healthcare organizations nationwide to turn insights into action. Together, we help teams move from goals to measurable progress. Integrity Advantage is a certified Women’s Business Enterprise (WBE) and Economically Disadvantaged Woman Owned Small Business (EDWOSB).
YOUR ONE-STOP-SHOP FOR HEALTHCARE FRAUD, WASTE, AND ABUSE SERVICES!
With more than 30 years of experience supporting payers, the team at Integrity Advantage provides healthcare fraud, waste and abuse consulting, outsourced investigations and medical record reviews for Special Investigations Units and other organizations fighting healthcare fraud. We are a certified Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).
For more information click below, call us at 866-644-7799 or email info@integrityadvantage.com.