{ "id": "AIBD-0187", "title": "Medicare withholds $4.41 billion in suspected fraudulent payments", "summary": "Federal analysts flagged unusual billing, and HHS-OIG and CMS held $4.41 billion in escrow during Operation Gold Rush.", "date_observed": "2025-06-30", "date_basis": "source publication", "date_precision": "day", "benefit_status": "reported", "source_collection": null, "source_entry": null, "account": "DOJ reported that analysts detected unusual billing in Operation Gold Rush. HHS-OIG and CMS held $4.41 billion in escrow from about $4.45 billion scheduled for payment. Medicare paid about $41 million, and supplemental insurers paid about $900 million. DOJ stated that HHS and CMS intended to seek the return of the escrow to the Medicare trust fund. The announcement also proposed an AI-enabled Data Fusion Center. It does not establish that AI was used in the Gold Rush detection.", "category": "harm prevented", "unexpected": false, "purpose": "Detect, investigate and prosecute complex health care fraud schemes.", "system": "DOJ Health Care Fraud Unit proactive billing analytics", "model_version": null, "developer": "U.S. Department of Justice, Criminal Division Fraud Section, Health Care Fraud Unit Data Analytics Team", "deployer": "U.S. Department of Justice with HHS-OIG and CMS", "location": null, "domain": "Health care fraud and public insurance", "segment": "Medicare durable medical equipment claims", "benefit_type": "Reduced Risk", "taxonomy_note": null, "registry_ids": {}, "ratings": [ { "group": "societal", "depth": 4, "reason": "The release states that $4.41 billion scheduled to be paid by Medicare was held in escrow for return to the Medicare trust fund. Supplemental insurers still paid about $900 million." }, { "group": "organizational", "depth": 3, "reason": "CMS and HHS-OIG stopped payment of all but about $41 million of $4.45 billion in claims from the organization, per the release." }, { "group": "personal", "depth": null, "reason": "The release describes over one million stolen identities but documents no outcome for the individual beneficiaries." } ], "ai_role": { "status": "unassessed", "statement": "DOJ attributes detection to proactive data analytics. The reviewed sources do not establish that AI was used. The AI-enabled Data Fusion Center was announced separately as future work." }, "evidence": [ { "kind": "press release", "citation": "U.S. Department of Justice, Office of Public Affairs, “National Health Care Fraud Takedown Results in 324 Defendants Charged in Connection with Over $14.6 Billion in Alleged Fraud,” June 30, 2025, § “Transnational Criminal Organizations.”", "title": "National Health Care Fraud Takedown Results in 324 Defendants Charged in Connection with Over $14.6 Billion in Alleged Fraud", "url": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "date": "2025-06-30", "written_by": "deployer", "quote": "The Health Care Fraud Unit's Data Analytics Team and its partners detected the anomalous billing through proactive data analytics" }, { "kind": "press release", "citation": "U.S. Department of Justice, Office of Public Affairs, press release, 3 February 2026. Brooklyn Banker Pleads Guilty to Laundering Proceeds of Medicare Fraud for Transnational Criminal Organization.", "title": "Brooklyn Banker Pleads Guilty to Laundering Proceeds of Medicare Fraud for Transnational Criminal Organization", "url": "https://www.justice.gov/opa/pr/brooklyn-banker-pleads-guilty-laundering-proceeds-medicare-fraud-transnational-criminal", "date": "2026-02-03", "written_by": "deployer", "quote": null }, { "kind": "court document", "citation": "United States v. Nakhmatullaev et al., No. 25-cr-203, indictment, June 18, 2025, 1–10, ¶¶ 1–20, 32–34 (E.D.N.Y.).", "title": "United States v. Nakhmatullaev et al., indictment", "url": "https://www.justice.gov/criminal/media/1405326/dl?inline=", "date": "2025-06-18", "written_by": "deployer", "quote": null }, { "kind": "press release", "citation": "U.S. Department of Justice, Office of Public Affairs, “Ohio Man Pleads Guilty to Laundering Health Care Fraud Proceeds for Transnational Criminal Organization,” August 14, 2026, ¶¶ 1–9.", "title": "Ohio Man Pleads Guilty to Laundering Health Care Fraud Proceeds for Transnational Criminal Organization", "url": "https://www.justice.gov/opa/pr/ohio-man-pleads-guilty-laundering-health-care-fraud-proceeds-transnational-criminal", "date": "2026-08-14", "written_by": "deployer", "quote": null } ], "replication": { "produced_by": [ "Analysts detected anomalous Medicare billing.", "HHS-OIG and CMS suspended scheduled payments." ], "must_hold": [ "Access to billing data before payment.", "Legal authority and operational capacity to suspend payments." ], "echoes": [] }, "paired_incident": null, "headline": "Medicare withholds $4.41 billion in suspected fraudulent payments", "metric": "HHS-OIG and CMS prevented all but $41 million of $4.45 billion", "comparator": { "against": "the amount Medicare was scheduled to pay on the fraudulent claims had the billing gone undetected", "before": "the approximately $4.45 billion that was scheduled to be paid by Medicare", "after": "all but approximately $41 million", "basis": "measured", "quote": "The Health Care Fraud Unit's Data Analytics Team and its partners detected the anomalous billing through proactive data analytics, and HHS-OIG and CMS successfully prevented the organization from receiving all but approximately $41 million of the approximately $4.45 billion that was scheduled to be paid by Medicare.", "url": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146" }, "later": { "status": "litigated", "date": "2026-08-13", "note": "DOJ reported 35 people charged and 16 convicted by August 14, 2026, following a money-laundering guilty plea the previous day. These developments do not establish an AI contribution or the final disposition of the $4.41 billion in escrow.", "quote": null, "url": "https://www.justice.gov/opa/pr/ohio-man-pleads-guilty-laundering-health-care-fraud-proceeds-transnational-criminal" }, "value": { "amount": "$4.41 billion", "what": "fraudulent Medicare payments held in escrow rather than paid out, to be returned to the Medicare trust fund", "who": "Medicare trust fund (HHS and CMS)", "estimate": false, "quote": "HHS and CMS intend to seek to return the $4.41 billion in escrow to the Medicare trust fund for needed medical care.", "url": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146" }, "developer_country": "United States", "deployer_country": "United States", "unrated_because": null, "brief_notes": null, "brief": null, "revisions": [ { "date": "2026-10-20", "change": "Record drafted from the cited sources.", "source": null, "editor": "AIBD" }, { "date": "2026-10-21", "change": "Benefit type set to Reduced Risk under Trustible's full taxonomy of 23 types; it was Improved Organizational Efficiency among the six first used.", "source": "https://trustible.ai/post/a-framework-for-measuring-the-benefits-of-ai/", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Added what the benefit is measured against, what happened since, the value as stated from the cited sources.", "source": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146; https://www.justice.gov/opa/pr/brooklyn-banker-pleads-guilty-laundering-proceeds-medicare-fraud-transnational-criminal; https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Country of the developer and the deployer added from the organization's own site or a registry.", "source": "https://www.justice.gov/contact-us; https://www.justice.gov/contact-us", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Prose pass: a rating reason, account, the replication conditions, the system's part rewritten in shorter sentences with abbreviations expanded; facts, figures and quotations unchanged.", "source": null, "editor": "AIBD" }, { "date": "2026-10-25", "change": "Read the original DOJ announcements and linked indictment; separated billing analytics from the proposed AI-enabled Fusion Center, clarified escrow and losses, and added the August 2026 prosecution update.", "source": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "editor": "AIBD" } ], "confidence": "claimed", "shade": "low", "claim_status": "The deployer's account", "claim_basis": "Sources: the deployer's court document and three press releases from the deployer. The cited evidence includes no independent source and no finding by a regulator or court.", "profile": { "case_id": "AIBD-0187", "catalog_version": "1.0.0", "source_fingerprint": "97b6aaeb2665f23ec816fe89bd7d400e53a9861274835d537c0b95d803e7f548", "collection_refs": [ { "collection_id": "aibd", "version": "snapshot-8bf7cfec9cb185aa" }, { "collection_id": "aibd", "version": "2026-10-25" }, { "collection_id": "querist", "version": "2026-10-25" }, { "collection_id": "adyt", "version": "2026-10-25" }, { "collection_id": "chanticleer", "version": "2026-10-25" } ], "source_ids": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "families": { "strategic assessments": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "record_ids": [] }, "evaluations": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "record_ids": [] }, "monetary observations": { "state": "value_present", "value": { "kind": "identifiers", "identifiers": [ "DIV-0026" ], "role": "monetary observations" }, "provenance": { "kind": "source_review", "basis": "DOJ reports a gross payment hold, without an established AI contribution.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "record_ids": [ "DIV-0026" ] }, "institutional decisions": { "state": "value_present", "value": { "kind": "identifiers", "identifiers": [ "25-cr-203" ], "role": "institutional decisions" }, "provenance": { "kind": "source_review", "basis": "DOJ announcement and the linked indictment.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0003" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "record_ids": [ "25-cr-203" ] } }, "fields": { "actors[]": { "state": "value_present", "value": { "kind": "text", "text": "DOJ’s Health Care Fraud Unit and partners analyzed billing. HHS-OIG and CMS suspended payments." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ’s Health Care Fraud Unit and partners analyzed billing. HHS-OIG and CMS suspended payments." } }, "actors[].ownership_control": { "state": "value_present", "value": { "kind": "text", "text": "The named teams are U.S. federal agencies. The sources do not identify a private software owner." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The named teams are U.S. federal agencies. The sources do not identify a private software owner." } }, "ai_contribution": { "state": "value_present", "value": { "kind": "text", "text": "DOJ credits proactive data analytics. It does not identify an AI component or measure its separate contribution." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ credits proactive data analytics. It does not identify an AI component or measure its separate contribution." } }, "ai_relationship": { "state": "unresolved", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "reason": "Whether the billing analysis used AI remains unresolved.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Whether the billing analysis used AI remains unresolved." } }, "assessments[].alternatives": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial" }, "assessments[].assessor_date": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial" }, "assessments[].depth": { "state": "value_present", "value": { "kind": "record_fields", "fields": { "ratings": [ { "group": "societal", "depth": 4, "reason": "The release states that $4.41 billion scheduled to be paid by Medicare was held in escrow for return to the Medicare trust fund. Supplemental insurers still paid about $900 million." }, { "group": "organizational", "depth": 3, "reason": "CMS and HHS-OIG stopped payment of all but about $41 million of $4.45 billion in claims from the organization, per the release." }, { "group": "personal", "reason": "The release describes over one million stolen identities but documents no outcome for the individual beneficiaries." } ] } }, "provenance": { "kind": "legacy_record", "basis": "Preserved from the existing AIBD record; external sources were not rechecked.", "record_fields": [ "ratings" ], "source_refs": [] }, "review_state": "record_mapped", "coverage": "partial" }, "assessments[].display_confidence": { "state": "value_present", "value": { "kind": "text", "text": "An outline: the payment figure comes from the participating agencies, and an AI contribution remains unresolved." }, "provenance": { "kind": "curatorial", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "An outline: the payment figure comes from the participating agencies, and an AI contribution remains unresolved." } }, "assessments[].rationale": { "state": "value_present", "value": { "kind": "record_fields", "fields": { "ratings": [ { "group": "societal", "depth": 4, "reason": "The release states that $4.41 billion scheduled to be paid by Medicare was held in escrow for return to the Medicare trust fund. Supplemental insurers still paid about $900 million." }, { "group": "organizational", "depth": 3, "reason": "CMS and HHS-OIG stopped payment of all but about $41 million of $4.45 billion in claims from the organization, per the release." }, { "group": "personal", "reason": "The release describes over one million stolen identities but documents no outcome for the individual beneficiaries." } ] } }, "provenance": { "kind": "legacy_record", "basis": "Preserved from the existing AIBD record; external sources were not rechecked.", "record_fields": [ "ratings" ], "source_refs": [] }, "review_state": "record_mapped", "coverage": "partial" }, "assessments[].rubric_version": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial" }, "assessments[].status_basis": { "state": "value_present", "value": { "kind": "text", "text": "The payment hold is reported as completed. Returning the escrow to the Medicare trust fund was still intended." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The payment hold is reported as completed. Returning the escrow to the Medicare trust fund was still intended." } }, "assessments[].target": { "state": "value_present", "value": { "kind": "record_fields", "fields": { "ratings": [ { "group": "societal", "depth": 4, "reason": "The release states that $4.41 billion scheduled to be paid by Medicare was held in escrow for return to the Medicare trust fund. Supplemental insurers still paid about $900 million." }, { "group": "organizational", "depth": 3, "reason": "CMS and HHS-OIG stopped payment of all but about $41 million of $4.45 billion in claims from the organization, per the release." }, { "group": "personal", "reason": "The release describes over one million stolen identities but documents no outcome for the individual beneficiaries." } ] } }, "provenance": { "kind": "legacy_record", "basis": "Preserved from the existing AIBD record; external sources were not rechecked.", "record_fields": [ "ratings" ], "source_refs": [] }, "review_state": "record_mapped", "coverage": "partial" }, "availability": { "state": "not_reported", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "reason": "The reviewed sources do not provide public access to the analytic system.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The reviewed sources do not provide public access to the analytic system." } }, "brief": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial" }, "case_kind": { "state": "value_present", "value": { "kind": "text", "text": "A federal fraud investigation and administrative payment suspension." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "A federal fraud investigation and administrative payment suspension." } }, "case_links[]": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial" }, "claims[].evidence_links": { "state": "value_present", "value": { "kind": "text", "text": "The June 2025 announcement supports the payment figures. The indictment describes the alleged scheme. The later releases add prosecution updates." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The June 2025 announcement supports the payment figures. The indictment describes the alleged scheme. The later releases add prosecution updates." } }, "claims[].evidence_strength": { "state": "value_present", "value": { "kind": "text", "text": "Official accounts support the withheld-payment figure and prosecution updates. They do not establish that AI produced the benefit." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Official accounts support the withheld-payment figure and prosecution updates. They do not establish that AI produced the benefit." } }, "claims[].missingness": { "state": "value_present", "value": { "kind": "text", "text": "The algorithm, AI contribution, operating costs, false-positive rate, and final escrow disposition remain unestablished." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The algorithm, AI contribution, operating costs, false-positive rate, and final escrow disposition remain unestablished." } }, "claims[].proposition": { "state": "value_present", "value": { "kind": "text", "text": "Billing analysis contributed to the detection of a scheme whose scheduled payments were largely suspended." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Billing analysis contributed to the detection of a scheme whose scheduled payments were largely suspended." } }, "cross_border_flows[]": { "state": "value_present", "value": { "kind": "text", "text": "DOJ describes criminal transfers to overseas companies and accounts. It does not document cross-border movement of the analytic system, its training data, or its computing resources." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ describes criminal transfers to overseas companies and accounts. It does not document cross-border movement of the analytic system, its training data, or its computing resources." } }, "decisions[].action_outcome": { "state": "value_present", "value": { "kind": "text", "text": "Payments were suspended. The June 2025 indictment and later guilty pleas concern the alleged criminal scheme." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Payments were suspended. The June 2025 indictment and later guilty pleas concern the alleged criminal scheme." } }, "decisions[].grounds": { "state": "value_present", "value": { "kind": "text", "text": "Anomalous billing and evidence of fraudulent claims were the stated grounds. The sources do not give a separate test of AI’s contribution." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0003" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Anomalous billing and evidence of fraudulent claims were the stated grounds. The sources do not give a separate test of AI’s contribution." } }, "decisions[].institution_task": { "state": "value_present", "value": { "kind": "text", "text": "HHS-OIG and CMS suspended payments while DOJ and its partners investigated the alleged fraud." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "HHS-OIG and CMS suspended payments while DOJ and its partners investigated the alleged fraud." } }, "decisions[].success_criterion": { "state": "value_present", "value": { "kind": "text", "text": "The announcements describe preventing improper payments and prosecuting fraud. They do not specify a prospective numerical threshold for success." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The announcements describe preventing improper payments and prosecuting fraud. They do not specify a prospective numerical threshold for success." } }, "deployment_stage": { "state": "value_present", "value": { "kind": "text", "text": "Operational billing analysis supported an active investigation." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Operational billing analysis supported an active investigation." } }, "economics[].amount": { "state": "value_present", "value": { "kind": "text", "text": "US$4.41 billion held in escrow." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "US$4.41 billion held in escrow." } }, "economics[].costs[]": { "state": "not_reported", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "reason": "The reviewed sources do not quantify operating or enforcement costs.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The reviewed sources do not quantify operating or enforcement costs." } }, "economics[].counterfactual": { "state": "value_present", "value": { "kind": "text", "text": "About $4.45 billion was scheduled for payment; about $41 million was paid. This accounting comparison does not isolate AI’s effect." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "About $4.45 billion was scheduled for payment; about $41 million was paid. This accounting comparison does not isolate AI’s effect." } }, "economics[].currency_price_basis": { "state": "value_present", "value": { "kind": "text", "text": "U.S. dollars. The figures are nominal; no inflation adjustment is stated." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "U.S. dollars. The figures are nominal; no inflation adjustment is stated." } }, "economics[].gross_net": { "state": "value_present", "value": { "kind": "text", "text": "The figure is gross money withheld. It does not deduct investigation, prosecution, or administrative costs." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The figure is gross money withheld. It does not deduct investigation, prosecution, or administrative costs." } }, "economics[].measure_type": { "state": "value_present", "value": { "kind": "text", "text": "Scheduled payments withheld in escrow, rather than a realized net saving." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Scheduled payments withheld in escrow, rather than a realized net saving." } }, "economics[].period_unit": { "state": "value_present", "value": { "kind": "text", "text": "The Operation Gold Rush payment hold reported on June 30, 2025. The exact interval covered by the total is not specified." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The Operation Gold Rush payment hold reported on June 30, 2025. The exact interval covered by the total is not specified." } }, "economics[].realization": { "state": "value_present", "value": { "kind": "text", "text": "$4.41 billion was held in escrow. Returning it to the trust fund remained an intention in the announcement." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "$4.41 billion was held in escrow. Returning it to the trust fund remained an intention in the announcement." } }, "economics[].recipient_payer": { "state": "value_present", "value": { "kind": "text", "text": "Medicare was the scheduled payer; the Medicare trust fund was the intended recipient of returned escrow." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Medicare was the scheduled payer; the Medicare trust fund was the intended recipient of returned escrow." } }, "economics[].return_payback": { "state": "unresolved", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "reason": "A return or payback period cannot be calculated from the reviewed figures because costs and an AI contribution are unestablished.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "A return or payback period cannot be calculated from the reviewed figures because costs and an AI contribution are unestablished." } }, "economics[].valuation_method": { "state": "value_present", "value": { "kind": "text", "text": "DOJ reports the scheduled, paid, and escrowed amounts. No monetary valuation model is described." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ reports the scheduled, paid, and escrowed amounts. No monetary valuation model is described." } }, "evaluations[].ai_uplift": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].comparator": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].design": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].effect": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].exposure": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].id": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].measurement_method": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].metric": { "state": "not_assessed", "provenance": { "kind": "legacy_record", "basis": "Mapped from the existing case description without a new external source review.", "record_fields": [ "metric" ], "source_refs": [] }, "review_state": "not_assessed", "coverage": "partial", "family": "evaluations", "display": { "answer": "HHS-OIG and CMS prevented all but $41 million of $4.45 billion", "editor_note": "" } }, "evaluations[].reproduction_materials": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].setting_sample": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "evaluations[].uncertainty_limitations": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "evaluations" }, "external_references[]": { "state": "value_present", "value": { "kind": "text", "text": "United States v. Nakhmatullaev et al., No. 25-cr-203." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0003" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "United States v. Nakhmatullaev et al., No. 25-cr-203." } }, "follow_up[]": { "state": "value_present", "value": { "kind": "text", "text": "DOJ reported 35 people charged and 16 convicted by August 14, 2026, following a money-laundering guilty plea the previous day. These developments do not establish an AI contribution or the final disposition of the $4.41 billion in escrow." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0002", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ reported 35 people charged and 16 convicted by August 14, 2026, following a money-laundering guilty plea the previous day. These developments do not establish an AI contribution or the final disposition of the $4.41 billion in escrow." } }, "human_oversight": { "state": "value_present", "value": { "kind": "text", "text": "Federal analysts, investigators, prosecutors, and payment administrators performed distinct roles. The sources do not describe a specific review protocol for software alerts." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Federal analysts, investigators, prosecutors, and payment administrators performed distinct roles. The sources do not describe a specific review protocol for software alerts." } }, "id": { "state": "value_present", "value": { "kind": "record_fields", "fields": { "id": "AIBD-0187" } }, "provenance": { "kind": "legacy_record", "basis": "Preserved from the existing AIBD record; external sources were not rechecked.", "record_fields": [ "id" ], "source_refs": [] }, "review_state": "record_mapped", "coverage": "partial" }, "infrastructure_dependencies[]": { "state": "value_present", "value": { "kind": "text", "text": "The investigation required Medicare billing records, access to payment administration, and cooperation among federal agencies." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The investigation required Medicare billing records, access to payment administration, and cooperation among federal agencies." } }, "outcomes[].beneficiaries": { "state": "value_present", "value": { "kind": "text", "text": "Medicare and the public funds that support it." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Medicare and the public funds that support it." } }, "outcomes[].beneficiary_count": { "state": "value_present", "value": { "kind": "text", "text": "More than one million people had identities stolen. That is a count of people affected by the alleged fraud, not a measured count of people helped by AI." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0003" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "More than one million people had identities stolen. That is a count of people affected by the alleged fraud, not a measured count of people helped by AI." } }, "outcomes[].benefit_type": { "state": "value_present", "value": { "kind": "text", "text": "Avoided payment of suspected fraudulent claims." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Avoided payment of suspected fraudulent claims." } }, "outcomes[].claim": { "state": "value_present", "value": { "kind": "text", "text": "$4.41 billion in scheduled Medicare payments was held in escrow." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "$4.41 billion in scheduled Medicare payments was held in escrow." } }, "outcomes[].distribution": { "state": "not_reported", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "reason": "The announcement does not measure how the payment hold benefited particular beneficiaries or communities.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The announcement does not measure how the payment hold benefited particular beneficiaries or communities." } }, "outcomes[].duration": { "state": "value_present", "value": { "kind": "text", "text": "The money was held by June 30, 2025. The reviewed sources do not establish the final disposition of the escrow." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The money was held by June 30, 2025. The reviewed sources do not establish the final disposition of the escrow." } }, "outcomes[].id": { "state": "value_present", "value": { "kind": "text", "text": "AIBD-0187-outcome-01" }, "provenance": { "kind": "curatorial", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "AIBD-0187-outcome-01" } }, "outcomes[].stakeholder_group": { "state": "value_present", "value": { "kind": "record_fields", "fields": { "ratings": [ { "group": "societal", "depth": 4, "reason": "The release states that $4.41 billion scheduled to be paid by Medicare was held in escrow for return to the Medicare trust fund. Supplemental insurers still paid about $900 million." }, { "group": "organizational", "depth": 3, "reason": "CMS and HHS-OIG stopped payment of all but about $41 million of $4.45 billion in claims from the organization, per the release." }, { "group": "personal", "reason": "The release describes over one million stolen identities but documents no outcome for the individual beneficiaries." } ] } }, "provenance": { "kind": "legacy_record", "basis": "Preserved from the existing AIBD record; external sources were not rechecked.", "record_fields": [ "ratings" ], "source_refs": [] }, "review_state": "record_mapped", "coverage": "partial" }, "outcomes[].status": { "state": "value_present", "value": { "kind": "text", "text": "The payment suspension occurred. Return of the escrow to the Medicare trust fund remained intended." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The payment suspension occurred. Return of the escrow to the Medicare trust fund remained intended." } }, "outcomes[].tradeoffs": { "state": "value_present", "value": { "kind": "text", "text": "About $41 million reached the organization through Medicare, and supplemental insurers paid about $900 million. Enforcement costs and effects on legitimate payments are not quantified." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "About $41 million reached the organization through Medicare, and supplemental insurers paid about $900 million. Enforcement costs and effects on legitimate payments are not quantified." } }, "outcomes[].unexpected": { "state": "value_present", "value": { "kind": "text", "text": "Preventing fraudulent payments was an intended purpose of the analysis." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Preventing fraudulent payments was an intended purpose of the analysis." } }, "places[]": { "state": "value_present", "value": { "kind": "structured", "data": { "developer_country": "United States", "deployer_country": "United States", "location": "United States", "answer": "The analysis and payment administration occurred in the United States. The investigation involved overseas arrests and transfers." } }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The analysis and payment administration occurred in the United States. The investigation involved overseas arrests and transfers." } }, "purpose": { "state": "value_present", "value": { "kind": "text", "text": "Detect health care fraud before scheduled payments leave Medicare." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Detect health care fraud before scheduled payments leave Medicare." } }, "record_dates": { "state": "value_present", "value": { "kind": "record_fields", "fields": { "date_observed": "2025-06-30", "date_basis": "source publication", "date_precision": "day", "revisions": [ { "date": "2026-10-20", "change": "Record drafted from the cited sources.", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Benefit type set to Reduced Risk under Trustible's full taxonomy of 23 types; it was Improved Organizational Efficiency among the six first used.", "source": "https://trustible.ai/post/a-framework-for-measuring-the-benefits-of-ai/", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Added what the benefit is measured against, what happened since, the value as stated from the cited sources.", "source": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146; https://www.justice.gov/opa/pr/brooklyn-banker-pleads-guilty-laundering-proceeds-medicare-fraud-transnational-criminal; https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Country of the developer and the deployer added from the organization's own site or a registry.", "source": "https://www.justice.gov/contact-us; https://www.justice.gov/contact-us", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Prose pass: a rating reason, account, the replication conditions, the system's part rewritten in shorter sentences with abbreviations expanded; facts, figures and quotations unchanged.", "editor": "AIBD" }, { "date": "2026-10-25", "change": "Read the original DOJ announcements and linked indictment; separated billing analytics from the proposed AI-enabled Fusion Center, clarified escrow and losses, and added the August 2026 prosecution update.", "source": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "editor": "AIBD" } ] } }, "provenance": { "kind": "legacy_record", "basis": "Preserved from the existing AIBD record; external sources were not rechecked.", "record_fields": [ "date_observed", "date_basis", "date_precision", "revisions" ], "source_refs": [] }, "review_state": "record_mapped", "coverage": "partial" }, "replication.attempts[]": { "state": "not_reported", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "reason": "The reviewed sources do not describe an independent replication of the billing analysis.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The reviewed sources do not describe an independent replication of the billing analysis." } }, "replication.conditions": { "state": "value_present", "value": { "kind": "text", "text": "The agencies needed billing data and the authority to stop payments before the money was transferred." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The agencies needed billing data and the authority to stop payments before the money was transferred." } }, "revision_history[]": { "state": "value_present", "value": { "kind": "record_fields", "fields": { "revisions": [ { "date": "2026-10-20", "change": "Record drafted from the cited sources.", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Benefit type set to Reduced Risk under Trustible's full taxonomy of 23 types; it was Improved Organizational Efficiency among the six first used.", "source": "https://trustible.ai/post/a-framework-for-measuring-the-benefits-of-ai/", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Added what the benefit is measured against, what happened since, the value as stated from the cited sources.", "source": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146; https://www.justice.gov/opa/pr/brooklyn-banker-pleads-guilty-laundering-proceeds-medicare-fraud-transnational-criminal; https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Country of the developer and the deployer added from the organization's own site or a registry.", "source": "https://www.justice.gov/contact-us; https://www.justice.gov/contact-us", "editor": "AIBD" }, { "date": "2026-10-21", "change": "Prose pass: a rating reason, account, the replication conditions, the system's part rewritten in shorter sentences with abbreviations expanded; facts, figures and quotations unchanged.", "editor": "AIBD" }, { "date": "2026-10-25", "change": "Read the original DOJ announcements and linked indictment; separated billing analytics from the proposed AI-enabled Fusion Center, clarified escrow and losses, and added the August 2026 prosecution update.", "source": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "editor": "AIBD" } ] } }, "provenance": { "kind": "legacy_record", "basis": "Preserved from the existing AIBD record; external sources were not rechecked.", "record_fields": [ "revisions" ], "source_refs": [] }, "review_state": "record_mapped", "coverage": "partial" }, "sector": { "state": "value_present", "value": { "kind": "text", "text": "Public health insurance and fraud enforcement." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Public health insurance and fraud enforcement." } }, "sources[].access_version": { "state": "value_present", "value": { "kind": "text", "text": "DOJ’s original online releases and the June 18, 2025 indictment were inspected on October 25, 2026." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ’s original online releases and the June 18, 2025 indictment were inspected on October 25, 2026." } }, "sources[].citation_locator": { "state": "value_present", "value": { "kind": "record_fields", "fields": { "evidence": [ { "kind": "press release", "citation": "U.S. Department of Justice, Office of Public Affairs, “National Health Care Fraud Takedown Results in 324 Defendants Charged in Connection with Over $14.6 Billion in Alleged Fraud,” June 30, 2025, § “Transnational Criminal Organizations.”", "title": "National Health Care Fraud Takedown Results in 324 Defendants Charged in Connection with Over $14.6 Billion in Alleged Fraud", "url": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "date": "2025-06-30", "written_by": "deployer", "quote": "The Health Care Fraud Unit's Data Analytics Team and its partners detected the anomalous billing through proactive data analytics" }, { "kind": "press release", "citation": "U.S. Department of Justice, Office of Public Affairs, press release, 3 February 2026. Brooklyn Banker Pleads Guilty to Laundering Proceeds of Medicare Fraud for Transnational Criminal Organization.", "title": "Brooklyn Banker Pleads Guilty to Laundering Proceeds of Medicare Fraud for Transnational Criminal Organization", "url": "https://www.justice.gov/opa/pr/brooklyn-banker-pleads-guilty-laundering-proceeds-medicare-fraud-transnational-criminal", "date": "2026-02-03", "written_by": "deployer" }, { "kind": "court document", "citation": "United States v. Nakhmatullaev et al., No. 25-cr-203, indictment, June 18, 2025, 1–10, ¶¶ 1–20, 32–34 (E.D.N.Y.).", "title": "United States v. Nakhmatullaev et al., indictment", "url": "https://www.justice.gov/criminal/media/1405326/dl?inline=", "date": "2025-06-18", "written_by": "deployer" }, { "kind": "press release", "citation": "U.S. Department of Justice, Office of Public Affairs, “Ohio Man Pleads Guilty to Laundering Health Care Fraud Proceeds for Transnational Criminal Organization,” August 14, 2026, ¶¶ 1–9.", "title": "Ohio Man Pleads Guilty to Laundering Health Care Fraud Proceeds for Transnational Criminal Organization", "url": "https://www.justice.gov/opa/pr/ohio-man-pleads-guilty-laundering-health-care-fraud-proceeds-transnational-criminal", "date": "2026-08-14", "written_by": "deployer" } ] } }, "provenance": { "kind": "legacy_record", "basis": "Preserved from the existing AIBD record; external sources were not rechecked.", "record_fields": [ "evidence" ], "source_refs": [] }, "review_state": "record_mapped", "coverage": "partial" }, "sources[].id": { "state": "value_present", "value": { "kind": "identifiers", "identifiers": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "role": "Retained sources" }, "provenance": { "kind": "curatorial", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "4 retained sources." } }, "sources[].language": { "state": "value_present", "value": { "kind": "text", "text": "English." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "English." } }, "sources[].relationship": { "state": "value_present", "value": { "kind": "text", "text": "DOJ reports its own investigation and prosecutions. The indictment records prosecutors’ allegations, not a judicial finding about an AI benefit." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ reports its own investigation and prosecutions. The indictment records prosecutors’ allegations, not a judicial finding about an AI benefit." } }, "sources[].upstream_sources": { "state": "value_present", "value": { "kind": "structured", "data": { "lead_source_ref": "AIBD-0187-source-0001", "retained_source_order": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "origins": [ { "source_refs": [ "AIBD-0187-source-0001" ], "display_name": "U.S. Department of Justice", "url": "https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146", "contribution": "Reports the billing detection, scheduled payments, escrow, and losses. Announces the future AI-enabled center separately.", "locator": "§§ “Transnational Criminal Organizations” and “Breaking Down Silos in the Fight Against Health Care Fraud.”" }, { "source_refs": [ "AIBD-0187-source-0002" ], "display_name": "U.S. Department of Justice", "url": "https://www.justice.gov/opa/pr/brooklyn-banker-pleads-guilty-laundering-proceeds-medicare-fraud-transnational-criminal", "contribution": "Documents the banker’s guilty plea on February 3, 2026.", "locator": "¶¶ 1–5." }, { "source_refs": [ "AIBD-0187-source-0003" ], "display_name": "U.S. Department of Justice", "url": "https://www.justice.gov/criminal/media/1405326/dl?inline=", "contribution": "Original indictment underlying the announcement. Describes alleged ownership, billing, and money laundering; it does not establish an AI method.", "locator": "1–10, ¶¶ 1–20, 32–34." }, { "source_refs": [ "AIBD-0187-source-0004" ], "display_name": "U.S. Department of Justice", "url": "https://www.justice.gov/opa/pr/ohio-man-pleads-guilty-laundering-health-care-fraud-proceeds-transnational-criminal", "contribution": "Reports 35 people charged and 16 convicted by August 14, 2026.", "locator": "¶¶ 1–9." } ], "limitations": [ "No reviewed source identifies an AI component in the billing detection.", "The announcements do not document a final return of the escrowed money to the trust fund." ] } }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001", "AIBD-0187-source-0002", "AIBD-0187-source-0003", "AIBD-0187-source-0004" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ is the original source for the payment figures. Its linked indictment describes the alleged scheme; later announcements document guilty pleas." } }, "strategic_assessments[]": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial", "family": "strategic assessments" }, "summary": { "state": "value_present", "value": { "kind": "text", "text": "Federal analysts flagged unusual billing, and HHS-OIG and CMS held $4.41 billion in escrow during Operation Gold Rush." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Federal analysts flagged unusual billing, and HHS-OIG and CMS held $4.41 billion in escrow during Operation Gold Rush." } }, "systems[].autonomy_permissions": { "state": "value_present", "value": { "kind": "text", "text": "HHS-OIG and CMS controlled payment suspensions. The sources do not describe an autonomous system that could withhold funds." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "HHS-OIG and CMS controlled payment suspensions. The sources do not describe an autonomous system that could withhold funds." } }, "systems[].component_role": { "state": "value_present", "value": { "kind": "text", "text": "The analysts detected unusual billing. HHS-OIG and CMS then stopped most scheduled payments." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The analysts detected unusual billing. HHS-OIG and CMS then stopped most scheduled payments." } }, "systems[].deployment_configuration": { "state": "not_reported", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "reason": "The reviewed sources do not specify the software, hosting, or runtime settings.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The reviewed sources do not specify the software, hosting, or runtime settings." } }, "systems[].inputs_outputs": { "state": "value_present", "value": { "kind": "text", "text": "Analysts examined health care billing and identified anomalous patterns. The model inputs and alert format are not specified." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Analysts examined health care billing and identified anomalous patterns. The model inputs and alert format are not specified." } }, "systems[].model_name": { "state": "not_reported", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "reason": "The reviewed sources do not identify a model.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The reviewed sources do not identify a model." } }, "systems[].model_version": { "state": "not_reported", "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "reason": "The reviewed sources do not identify a model release.", "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The reviewed sources do not identify a model release." } }, "systems[].product_name": { "state": "value_present", "value": { "kind": "text", "text": "DOJ Health Care Fraud Unit proactive billing analytics" }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "DOJ Health Care Fraud Unit proactive billing analytics" } }, "systems[].provider": { "state": "value_present", "value": { "kind": "text", "text": "The Department of Justice identifies its Health Care Fraud Unit Data Analytics Team and partners; it names no software supplier." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "The Department of Justice identifies its Health Care Fraud Unit Data Analytics Team and partners; it names no software supplier." } }, "taxonomy_crosswalks[]": { "state": "not_assessed", "review_state": "not_assessed", "coverage": "partial" }, "title": { "state": "value_present", "value": { "kind": "text", "text": "Medicare withholds $4.41 billion in suspected fraudulent payments" }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Medicare withholds $4.41 billion in suspected fraudulent payments" } }, "version": { "state": "value_present", "value": { "kind": "identifiers", "identifiers": [ "97b6aaeb2665f23ec816fe89bd7d400e53a9861274835d537c0b95d803e7f548" ], "role": "SHA-256 of normalized original case data" }, "provenance": { "kind": "curatorial", "basis": "Content fingerprint refreshed after the October 25, 2026 source review.", "record_fields": [], "source_refs": [], "reviewed_on": "2026-10-25" }, "review_state": "record_mapped", "coverage": "complete" }, "workflow": { "state": "value_present", "value": { "kind": "text", "text": "Analysts detected anomalous billing; investigators examined the scheme, and HHS-OIG and CMS withheld scheduled payments." }, "provenance": { "kind": "source_review", "basis": "Original DOJ announcements and the linked indictment, reviewed October 25, 2026.", "record_fields": [], "source_refs": [ "AIBD-0187-source-0001" ], "reviewed_on": "2026-10-25" }, "review_state": "reviewed", "coverage": "complete", "display": { "answer": "Analysts detected anomalous billing; investigators examined the scheme, and HHS-OIG and CMS withheld scheduled payments." } } }, "summary": { "total": 91, "addressed": 91, "known": 64, "reviewed": 64, "record_mapped": 9, "not_assessed": 18, "complete": false, "by_state": { "value_present": 64, "not_reported": 7, "unresolved": 2, "not_assessed": 18, "not_applicable": 0, "withheld": 0, "source_unavailable": 0 } } } }