In an effort to accentuate their efforts towards well being care fraud, the U.S. Division of Justice (“DOJ”) and the Division of Well being and Human Providers (“HHS”) introduced on July 2, 2025, the creation of a DOJ-HHS False Claims Act (“FCA”) Working Group (the “Working Group”). Whereas DOJ and HHS have an extended historical past of collaborative work underneath the FCA, this initiative indicators a heightened and coordinated deal with investigating and prosecuting well being care fraud. The Working Group goals to streamline investigations, establish new leads and leverage HHS information and program integrity instruments to detect fraud which may in any other case go unnoticed, thereby rising FCA publicity for well being care suppliers.
Continued Efforts
In FY 2024, well being care fraud continued to be a serious goal of FCA enforcement. Well being care-related settlements and judgments accounted for over $1.67 billion of the whole $2.9 billion in FCA recoveries. Enforcement efforts focused a variety of suppliers, together with hospitals, expert nursing amenities, pharmacies, pharmaceutical firms and laboratories. The creation of the Working Group indicators follow-through on the White-Collar Enforcement Plan issued by the DOJ’s Prison Division on Could 12, 2025, which cited well being care fraud as a high-impact space.
Working Group Membership
The Working Group will embrace members from HHS Workplace of Basic Counsel, the Facilities for Medicare & Medicaid Providers (“CMS”) Heart for Program Integrity, the Workplace of Counsel to the HHS Workplace of Inspector Basic (“HHS-OIG”) and DOJ’s Civil Division.
Precedence Enforcement Areas
The Working Group has recognized the next areas as high priorities of their efforts to forestall well being care fraud by means of the FCA:
- Medicare Benefit fraud, together with threat adjustment fraud or inflating threat scores;
- Preparations involving drug and system pricing, together with medically pointless prescriptions or billing for non-FDA-approved makes use of;
- Boundaries to affected person entry to care, together with community adequacy necessities;
- Kickbacks associated to well being care services and products, with a selected emphasis on medicine, units and sturdy medical gear;
- Materially faulty medical units impacting affected person security, together with making deceptive statements a couple of system’s security or effectiveness; and
- Manipulation of Digital Well being Data methods to inflate claims or assist pointless companies.
The Working Group encourages each whistleblowers and well being care firms to establish and report FCA violations, particularly inside these precedence enforcement areas.
Sensible Takeaways
- The Working Group demonstrates a continued dedication to investigating and taking enforcement motion concerning supplier non-compliance.
- Suppliers ought to take proactive steps to evaluation and bolster their compliance applications, with a selected emphasis on auditing, monitoring and implementing corrective actions, particularly as they relate to the recognized precedence areas.
- The Working Group’s emphasis on encouraging whistleblowers to report potential violations highlights the necessity for suppliers to have clear channels for workers to report considerations with out worry of retaliation.
Corridor Render will proceed to trace and supply updates on this Working Group’s exercise. In case you have questions or would really like extra details about this matter, please contact:
Particular because of Summer season Affiliate David Yanda for his help within the preparation of this text.
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