Heightened Scrutiny of Health Care Fraud: What Providers Need to Know Looking Ahead, by Abbye Alexander, Esq., Christopher Tellner, Esq., and Henry Norwood, Esq., 10-31-2025

Health care fraud continues to be a major focus of federal enforcement, with significant implications for providers, suppliers, and health care entities. Recent actions by the Department of Justice (DOJ) underscore an expanding crackdown targeting a broad array of alleged fraudulent schemes. As the DOJ ramps up resources and investigations, health care entities should be aware of the evolving landscape and prepare accordingly to mitigate risks of enforcement.

Record-Breaking National Health Care Fraud Takedown

In June 2025, the DOJ announced the largest coordinated health care fraud enforcement action in its history, charging 324 defendants in connection with various health care fraud schemes involving more than $14.6 billion in intended loss, according to the agency. This sweep, conducted across 50 federal districts with cooperation from 12 state attorneys general, encompassed nearly 100 licensed medical professionals, including doctors, nurse practitioners, and pharmacists, reflecting increased scrutiny on individual as well as organizational providers.

The alleged illegal conduct involved schemes such as prescription opioid trafficking, telemedicine and genetic testing fraud, kickbacks, and false billings. Notably, one case—dubbed Operation Gold Rush—exposed a transnational criminal organization that submitted $10.6 billion in fraudulent claims for durable medical equipment by exploiting stolen patient identities. Federal authorities emphasized that advanced data analytics, cloud computing, and artificial intelligence played critical roles in detecting these large-scale fraud networks before most fraudulent payments were disbursed.

Expansion of Specialized Enforcement Units

Acknowledging health care and life sciences as major sectors vulnerable to fraud, the DOJ recently expanded its Health Care Fraud Unit’s New England Strike Force to include the District of Massachusetts, a vital hub for health care innovation and services. This expansion boosts investigative and prosecutorial capacity, enabling more focused actions targeting complex fraud schemes involving pharmaceuticals, medical devices, providers, and corporate executives.

These specialized strike forces are made up of investigators and prosecutors and focus on the worst offenders engaged in fraudulent activities, including, mainly, health care fraud, wire fraud, mail fraud, bank fraud, money laundering offenses, and Anti-Kickback Statute violations among other offenses, according to the DOJ’s Strike Force Operations site. The first strike force was launched in March 2007 and today there are multiple Strike Forces in operation including New England’s (a complete list can be found here).

Increasing Focus on False Claims Act Enforcement

Further heightening the risks to providers, this past July, the DOJ and the Department of Health and Human Services (HHS) announced the relaunch of the DOJ-HHS False Claims Act Working Group with priority enforcement areas that include Medicare Advantage, kickbacks related to drugs, medical devices, durable medical equipment, and other products paid for by federal healthcare programs and manipulation of Electronic Health Records systems to drive inappropriate utilization of Medicare covered products and services.

The renewed emphasis on FCA enforcement signals that entities submitting claims to Medicare, Medicaid, and other federal health programs must maintain heightened compliance vigilance. Providers should anticipate more aggressive government oversight and a lower tolerance for practices viewed as exploitative or deceptive.

Preparing for Heightened Oversight

Given the magnitude and diversity of recent enforcement activity, health care entities should consider:

• Strengthening internal fraud detection and compliance programs utilizing advanced data analytics.
• Paying close attention to evolving regulation and enforcement priorities, including expanded FCA focus areas.
• Enhancing training and awareness for medical and administrative staff regarding fraud risks and reporting obligations.
• Engaging proactively with legal counsel to review billing practices, contracts, and compliance policies.
• Preparing for potential increased government audits and investigations by maintaining thorough documentation and controls.

The DOJ’s intensified commitment to combatting health care fraud reflects its dedication to protecting patients, taxpayers, and the integrity of critical health programs. Health care providers and organizations must respond with equally robust measures to mitigate risk and uphold ethical standards in this high-scrutiny environment.

Authors: Abbye Alexander and Christopher Tellner, Co-Chairs of the Health Care/Managed Care Practice Group and Of Counsel Henry Norwood