DOJ Targets Health Care Fraud: Record Settlements and Regulatory Enhancements

The Department of Justice (DOJ) remains vigilant against waste, fraud, and abuse in federal programs, prominently targeting health care fraud alongside program and procurement fraud. In conjunction with the Department of Health and Human Services (HHS), the DOJ has launched a False Claims Act Working Group to address fraud in federal healthcare programs, demonstrating a concerted effort to uphold regulatory compliance.

In fiscal year 2025, the DOJ reported a record $6.8 billion in settlements and judgments under the False Claims Act, with health care-related cases accounting for more than $5.7 billion. This highlights the imperative for comprehensive compliance programs among healthcare providers and entities engaged in federal health care initiatives. Primary enforcement priorities include fraud in Medicare Advantage, prescription drug pricing manipulation, and violations related to copay assistance and medically unnecessary services.

The Centers for Medicare & Medicaid Services (CMS) and HHS have issued a Request for Information (RFI) to solicit feedback on potential regulatory enhancements aimed at bolstering program integrity. Health care stakeholders are encouraged to review the RFI and provide input before the March 30 deadline, offering a crucial opportunity to shape future regulatory frameworks. Health care organizations should reassess their compliance strategies, focusing on internal audits, accurate coding, enrollment controls, and anti-kickback measures to mitigate enforcement risks amid heightened governmental scrutiny.