Monthly Newsletter

September 2025 Monthly Newsletter

In This Issue -

Artificial Intelligence (AI) and XAI
How Fraud & Abuse Endangers Patients
Healthcare Compliance for Patient Safety and Quality

DOJ Expands UnitedHealth Group Criminal Investigation
Compliance Director and Office Manager Convicted

Artificial Intelligence (AI) and XAI

Generative AI Use and Management at Federal Agencies

GAO-25-107653 Published: Jul 29, 2025, Fast Facts indicates that generative AI could dramatically increase productivity and transform the federal government workplace. “From 2023 to 2024, agencies’ use of generative AI increased ninefold. As agencies deploy generative AI, they report encountering challenges such as complying with federal policies while keeping up with this rapidly evolving technology”.

Generative artificial intelligence (generative AI) is a type of AI that can create new content and ideas, including conversations, stories, images, videos, and music. It can learn human language, programming languages, art, chemistry, biology, or any complex subject matter.

Agency officials told GAO that they face several challenges to using generative AI, such as complying with existing federal policies and guidance, having sufficient technical resources and budget, and maintaining up-to-date appropriate use policies.

For example, officials at 10 of 12 selected agencies said existing federal policy, such as data privacy policy, could present obstacles to adoption.

Furthermore, officials at four agencies told GAO that the technology’s rapid evolution can complicate establishment of generative AI policies and practices.

So, What About XAI?

Explainable Artificial Intelligence/Machine Learning is referred to as “XIA.” As healthcare delves deeper into AI implementation, understanding XIA may bring a little more trust. Why? It allows non-technical users to comprehend AI outputs, fostering greater confidence and acceptance of AI systems in daily life.

Explainable AI/ML (XAI) is the practice of creating artificial intelligence and machine learning systems that can provide clear, understandable reasons for their decisions and actions, rather than operating as "black boxes". The goal of XAI is to increase transparency and trust in AI systems by showing how they work, which helps developers debug models, users understand outcomes, and stakeholders ensure fairness, accountability, and the absence of biases.

Federal agencies are actively using and investing in Explainable AI (XAI). Because government AI applications often involve sensitive data and high-stakes decisions, XAI is a critical requirement for ensuring transparency, accountability, and public trust. Learn more – here are 2 references you may be interested in reading:

IBM has published an informative, easy-to-read article on this topic – click here
The AI Journal Explainable AI in Government: Transparency, Trust, and Traceability
AIHC publishes compliance articles addressing AI issues in healthcare– click here

How Fraud & Abuse Endangers Patients

Healthcare fraud and abuse directly endanger patients by exposing them to unnecessary or harmful medical treatments, mismanaging their medical records, and eroding the crucial trust between patients and providers. The billions of dollars lost to fraud and abuse each year drain resources that could be invested in improving legitimate patient care.

Fraudulent billing often requires falsifying patient diagnoses and medical histories to justify fabricated services. The resulting inaccuracies can, at minimum:

Remain in a patient's health record for years, complicating future treatment.
Cause inappropriate pre-existing conditions noted by health insurance.
Increase out-of-pocket costs to patients, making healthcare unaffordable.
- Patients may receive large bills for services never rendered or for unnecessary treatments.
- Victims' credit scores and financial stability can be damaged by unmanageable debt from fraudulent claims; and
Cause legitimate healthcare providers to make poor decisions based on incorrect information.

When a provider prioritizes financial gain over patient well-being, medical decisions become skewed and unreliable. Schemes often lead to harmful acts, such as:

Ordering expensive, unnecessary expensive diagnostic tests, such as MRIs, for simple conditions.
Misdiagnosing patients with more severe conditions to justify higher billing codes (upcoding).

These fraudulent practices also degrade the overall quality of care by diverting resources, inflating costs, and undermining the integrity of the entire healthcare system. Implementing an effective compliance program is critical to mitigate risk by revealing potential issues. Consider the following training resources offered by the American Institute of Healthcare Compliance, a licensing/certification partner w/CMS.

Auditing for Compliance – online training for healthcare auditors w/certification
Corporate Compliance – online training w/certification for healthcare executives
Revenue Cycle Management – compliance training for RCMs online w/certification

Healthcare Compliance for Patient Safety and Quality

Quality and compliance are interconnected and essential for a well-functioning healthcare system. Quality of care in healthcare compliance refers to adhering to standards and regulations that ensure care is safe, effective, patient-centered, timely, equitable, and efficient, while also ensuring compliance with laws to prevent fraud and abuse.

While compliance is about meeting minimum standards, quality is about achieving excellent outcomes and continuous improvement that go beyond basic requirements. Compliance is not a one-time fix but an ongoing effort. Frameworks enable continuous monitoring of performance and provide mechanisms for adjusting strategies as needed.

Quality Improvement (QI) frameworks - Frameworks provide structured methods to identify where a healthcare organization is failing to meet compliance standards. Frameworks such as Lean Six Sigma, Plan-Do-Study-Act (PDSA), and Continuous Quality Improvement (CQI), are used to enhance compliance. It provides a structured, data-driven processes to identify and resolve compliance gaps, standardize procedures, and continuously monitor adherence to regulations and laws. These frameworks help organizations achieve compliance through systematic process improvements, involving leadership, stakeholder engagement, data collection, and ongoing assessment to ensure sustainable adherence to healthcare standards.

The Centers for Medicare & Medicaid Services (CMS) promotes a QAPI (Quality Assurance and Performance Improvement) program framework with 5 key elements, including governance, leadership, data systems, performance improvement projects, and systematic action to ensure quality and compliance.

Learn more:

How to audit for compliance to quality standards and meet quality experts at the live 2-day Quality Workshop in Nashville on October 22-23, 2025.
Watch the recorded free webinar from August 21, 2025, now posted to the AIHC YouTube Channel - Improving Quality is Crucial to Sustain Your Practice

DOJ expands UnitedHealth Group Criminal Investigation

In July, UnitedHealth said it was complying with criminal and civil investigations into its Medicare Advantage business. The disclosure came after The Wall Street Journal reported in May that the DOJ has been investigating allegations of Medicare Advantage billing and coding fraud at the company and interviewing former employees since at least 2024.

The Justice Department also has a civil fraud investigation into the company’s Medicare billing practices that’s separate from the criminal inquiry, which was first reported by the Wall Street Journal in February. In July, UnitedHealth said it “has a long record of responsible conduct and effective compliance” and that it “is committed to maintaining the integrity of its business practices and serving as reliable stewards of American tax dollars.” Read UnitedHealth Group’s response to the investigation – click here

Compliance Director and Office Manager Convicted

The Office of Inspector General (OIG) has reported two former leaders of Life Touch LLC, a Kinston-based substance abuse treatment company, have pleaded guilty to their roles in a scheme to pay kickbacks to Medicaid patients.

Keke Komeko Johnson, of Pikeville, the Compliance Director, and Francine Sims Super, of Kinston, an Office Manager, admitted to their roles in a scheme involving the payment of kickbacks to patients, and tax violations. The collusion created a situation which could be difficult to detect.

To monitor healthcare management for corruption, a comprehensive strategy is needed that combines robust internal controls, data analytics, transparent reporting mechanisms, and external oversight. Since corruption can happen at all levels of the healthcare system, monitoring must be multi-pronged and consistent. A few helpful tips to implement could be:

Protect and reward whistleblowers by implementing strong policies that protect employees who report suspected misconduct, fraud, or corruption without fear of retaliation.
Segregate duties so that no single employee has unchecked control over billing, purchasing, and other financial processes. This includes requiring multiple approvals for procurement or contracting.
Conduct frequent and thorough audits of financial records, billing, and coding to proactively detect and address discrepancies.
To prevent collusion and ensure compliance, regularly scrutinize relationships and contracts with third-party vendors and suppliers.
Enforce strict policies that require staff and leaders to declare financial interests and other affiliations that could influence healthcare decisions.

A strong commitment to ethical behavior from top-level management sets a positive tone for the entire organization. This is achieved by implementing a Culture of Quality and Compliance. Regularly train employees on anti-fraud measures, ethical practices, and compliance standards. This ensures staff can recognize and report misconduct. Ensure that all health strategies, projects, and plans are built with anti-corruption and transparency mechanisms in mind from the outset.

Read more about this case - then think, what can you do to prevent this type of corruption in your organization?