5 Things Every Healthcare Provider Needs to Know About Fraud, Waste, and Abuse in 2026

Scrutiny of healthcare spending is at an all-time high. The Trump administration, state regulators, and commercial payors are all examining documentation more closely than ever — and for many provider groups, the question is no longer if they'll face a review, but when.

In a recent Brellium webinar, CEO Zach Rosen and former Medicaid Chief Medical Officer Dr. Andrey Ostrovsky broke down what's driving the current moment and what providers can do to stay ahead of it. Here are the five biggest takeaways.

1. The scrutiny is intense — and it's expanding.

Behavioral health, ABA, hospice, and addiction treatment are currently under the most intense review, fueled in part by high-profile investigations from outlets like the Wall Street Journal. But enforcement rarely stays contained. Once audits begin bearing fruit in one specialty or state, they tend to spread. Providers across all lines of care should be paying attention.

2. Your best compliance tool is a patient-first culture.

Counterintuitively, the organizations that fare best in audits aren't the ones with the biggest compliance departments. According to Dr. Ostrovsky, the most prepared organizations are the ones where clinicians are genuinely motivated to do right by their patients. When care is evidence-based and patient-centered, the documentation tends to support itself. Compliance becomes a byproduct of quality.

3. Compliance has to scale with your business.

A compliance program that works today may completely break down when you add a new state, a new payor, or a new line of care. Rosen emphasized that the best-in-class providers bake compliance into their operations from day one and hire leaders specifically capable of building programs that grow with the organization. Point-in-time fixes are not a long-term strategy.

4. Technology is necessary — but only with the right foundation.

Regulators and payors are now using AI to review documentation at scale. Providers need to keep pace. But technology is only as good as the workflows and culture behind it. As Rosen put it, if your clinicians aren't bought into patient-first care, the best platform in the world won't save you. The right sequence is culture first, then technology to reinforce and scale it.

5. States are tightening oversight on their own.

Heading into the second half of 2026, state Medicaid programs — particularly in California, New York, and Wisconsin — are proactively cracking down on fraud, waste, and abuse before federal pressure forces their hand. Providers operating across multiple states should expect that scrutiny to intensify at the state level, not just federally.

The bottom line: whether you're a growing behavioral health group or a large multistate provider, now is the time to assess where your compliance program stands, and whether it's built to last.