Healthcare Fraud Enforcement Trends: Lessons From the 2025 DOJ Takedown

For decades, The Fox Group has helped hospitals, physicians, and other healthcare organizations address healthcare compliance risk exposure involving federal healthcare programs. Our…

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Jim Hook, MPH

By Jim Hook, MPH | September 2, 2026

Healthcare fraud enforcement trends illustrated through connected medical records, data analytics, and federal enforcement networks.

For decades, The Fox Group has helped hospitals, physicians, and other healthcare organizations address healthcare compliance risk exposure involving federal healthcare programs. Our work has included evaluating billing and coding practices, physician financial arrangements, and other activities that can create exposure under federal fraud and abuse laws. That experience informs this review of recent healthcare fraud enforcement trends. Healthcare leaders can draw important lessons from the 2025 National Health Care Fraud Takedown.

Executive Summary – Key Takeaways

  • Federal healthcare fraud enforcement is increasingly data-driven and coordinated
  • Familiar fraud schemes persist despite more sophisticated enforcement tools
  • Transnational criminal organizations are becoming healthcare fraud actors
  • Compliance programs require annual reassessment as risks evolve
  • Healthcare organizations should use analytics to detect emerging compliance risks

Table of contents

The 2025 National Health Care Fraud Takedown demonstrates that federal healthcare fraud enforcement is becoming increasingly coordinated, data-driven, and technologically sophisticated. At the same time, many of the underlying fraud schemes remain familiar, even as federal agencies apply new tools and greater interagency coordination to identify and prosecute them.

We have encountered healthcare providers who wanted to go right up to the line in documenting and submitting claims to federal healthcare programs. However, we have not encountered clients like some of the providers highlighted in the June 2026 press release on healthcare fraud enforcement trends.

What Were the Headlines From These Latest Health Care Fraud Enforcement Actions?

The press release from the Federal Department of Justice highlighted several types of healthcare providers, criminal elements, and healthcare programs where fraud involving federal programs is occurring.

  • Healthcare providers ranged from physicians and nurse practitioners to pharmacists and other medical professionals in 50 federal districts. Criminals included members of transnational criminal organizations.
  • Law enforcement agencies included not only the US Department of Justice (DOJ) and the Centers for Medicare and Medicaid (CMS), but also the Health and Human Services (HHS) Office of Inspector General (OIG), and 12 State Attorneys General. 
  • Healthcare programs included Medicare and Medicaid. Clinical services included wound care, allopathic skin grafts, prescription opioid trafficking, telemedicine, and genetic testing claims fraud.
  • Fraudulent activities included medically unnecessary services, services billed for but never delivered, and kickbacks and bribes.
  • Overall, charges were filed against 324 defendants involving $14.6 billion in intended loss.

How Is the Federal Government Expanding Its Data-Driven Healthcare Fraud Enforcement Efforts?

The 2026 DOJ press release also highlights an earlier federal initiative: the Health Care Fraud Unit Data Analytics Team, which DOJ says was established in 2018. This inter-agency team includes staff from the DOJ, CMS, HHS OIG, DEA, and others. It describes itself as using advanced analytics, artificial intelligence, and cloud computing to uncover and prosecute healthcare fraud.

The 2026 DOJ press release reflects an expansion of this data-driven approach and emphasizes the government’s attempt to “break down silos in the fight against healthcare fraud.” This tactic involves creating a Health Care Fraud Data Fusion Center. It deploys representatives from more than a half dozen federal investigative and law enforcement efforts/agencies. These include the FBI, HHS OIG, DOJ Criminal Fraud Division, and others.

Who and What Are Federal Healthcare Fraud Enforcement Efforts Targeting?

The “Usual Suspects” in Healthcare Fraud Enforcement

Federal prosecutors continue to target physicians and other medical professionals who engage in well-known types of fraud or other misconduct involving government funds.

  • Prescription Opioid Trafficking, which involves physicians or nurse practitioners with independent ability to prescribe medications. 44 medical professionals were charged in 58 cases where diversion of prescriptions for opioids and other controlled substances was alleged. 
  • Fraudulent Wound Care, where five medical professionals were charged with administering unnecessary amniotic allografts. These are joint injections of amniotic fluid designed to reduce inflammation and enhance tissue repair in joints.
  • False and fraudulent claims that were for medically unnecessary services, services never actually performed, or unnecessary diagnostic medical tests. Many of these services were induced using kickbacks or bribes to intermediaries. 170 defendants were charged in these schemes.

The “Unusual Suspects”: Transnational Criminal Organizations

Transnational Criminal Organizations often buy existing medical providers such as DME companies and insert new owners using fake documents. They then begin submitting false claims for services such as urinary catheters or medical equipment never ordered or furnished.

The scheme described in the 2025 report received almost $1 billion in payments from Medicare over time!

False Claims Act Enforcement Efforts in 2026

Some of the larger False Claims Act (FCA) settlements in 2026 have involved institutional healthcare organizations such as pharmacy manufacturers and Accountable Care Organizations.

  • A New York health system agreed to pay $29 million to resolve allegations that it failed to refund excess payments by the Department of Defense for retired military and their families.
  • A Medicare Advantage plan, its related subsidiary, and a radiology group agreed to repay $62 million. The settlement resolved allegations they submitted inflated claims for services to patients with severe spinal conditions.
  • A drug company agreed to pay nearly $60 million to resolve allegations it violated the False Claims Act and Anti-Kickback Statute (AKS). The company allegedly paid remuneration to physicians to induce them to order a new migraine medication.
  • A health system and its affiliate agreed to pay $31.5 million to resolve alleged violations of the FCA, AKS, and Stark Law. The allegations involved monetary and non-monetary compensation to physicians intended to influence referrals to the health system. 

What Can Healthcare Leaders Learn From the Patterns in Fraud Enforcement — and What Should They Do About Them?

Lesson 1: “Everything Old Is New Again”

The filing of charges against transnational criminals may be relatively new. However, the activities they engaged in have been staples of certain healthcare fraud enforcement investigations for decades. These include corrupting medical supply or DME providers and improper billing. And False Claims Act, Anti-Kickback, and Stark Law enforcement efforts have never gone away.

Lesson 2: Don’t Assume Your Compliance Measures Are Working

Healthcare leaders should not assume they will find out about mistakes – or misconduct – early enough to prevent real financial or reputational damage. These days, compliance risks may change frequently, so annual review is mandatory.

  • Has your institution entered into new arrangements with existing physicians or new physicians? Are the medical directorships or other compensation arrangements at fair market value and necessary for the institution?
  • Have you identified new clinical services that should be added to the audit schedule? Do the medical records support the diagnostic and procedure coding used to bill for those services?
  • Have you updated your policy on non-monetary compensation to reflect the annual change in limits? Are you tracking that compensation to ensure those limits aren’t exceeded?
  • Are your marketing personnel intimately familiar with the Stark Law in general and your policy in particular? 
  • Are you utilizing the analytics available to your healthcare organization to spot trends in misuse or overuse of specific procedures or services? 

In any reasonably run healthcare organization, it is going to be hard for an individual to engage in fraudulent conduct that puts the organization at risk for enforcement investigations. But it is not impossible. And as we see year after year, CEOs and Boards can make major mistakes, too! Don’t get complacent!

What does the DOJ’s 2025 takedown reveal about how federal healthcare fraud is being detected?

Federal healthcare fraud enforcement has become increasingly coordinated, data-driven, technologically sophisticated, and collaborative across multiple agencies.

The DOJ’s 2025 takedown included a Health Care Fraud Data Fusion Center involving its own Fraud Section, HHS-OIG, the FBI, and other agencies. The DOJ says the effort uses cloud computing, artificial intelligence, and advanced analytics to identify emerging schemes. Its Health Care Fraud Unit Data Analytics Team also used analytics to identify and support investigations behind the takedown.

Have familiar healthcare fraud schemes become less important as enforcement technology advances?

No. Many familiar schemes, such as billing for medically unnecessary services, services never provided, kickbacks, and bribes remain central enforcement targets.

The 2025 takedown was a combination of newly sophisticated detection methods with long-standing fraud patterns in the areas of wound care, telemedicine, genetic testing, DME, controlled substances, and other services. The lesson learned is not that old schemes have disappeared, but that federal agencies now have better tools to identify them.

Why are transnational criminal organizations now relevant to healthcare compliance?

Transnational criminal organizations are becoming healthcare fraud actors. They have been known to buy existing medical providers, such as DME companies, and insert new owners using fake documents. Then, with new ownership in place, they begin submitting false claims for services or medical equipment never ordered or furnished.

How often should healthcare organizations reassess their compliance risks?

Healthcare organizations should reassess compliance risks at least annually and revisit them when operations or enforcement risks materially change.

Examples of items for review are physician arrangements, new clinical services, coding support, non-monetary compensation, marketing practices, and analytics. HHS-OIG’s voluntary General Compliance Program Guidance recommends at least annual compliance risk assessments and continued scanning for new risks between assessments.

How are federal agencies using data analytics and artificial intelligence to detect healthcare fraud?

Federal agencies increasingly use advanced analytics, artificial intelligence, cloud computing, and shared data to identify emerging healthcare fraud schemes.

The DOJ’s Health Care Fraud Data Fusion Center has brought together its own specialists along with HHS-OIG, the FBI, and other agencies. The DOJ says the center uses coordinated data analysis to break down silos and improve both fraud detection and prosecution.