On July 2, 2025, the U.S. Department of Justice (DOJ) and the Department of Health and Human Services (HHS) jointly announced the new working group to address healthcare fraud.
What happened
The DOJ and HHS unveiled the DOJ-HHS False Claims Act Working Group to enhance fraud detection and enforcement in federally funded healthcare programs. The administration intends to tighten oversight in areas like Medicare Advantage, drug pricing, network adequacy violations, and kickback schemes.
Under the False Claims Act (31 U.S.C. §§ 3729-3733), entities found to knowingly submit false claims to the government may be liable for treble damages and severe penalties. False claims liability also extends to cases where organizations knowingly avoid paying government funds, like through misreporting or underpayment.
The new group will include leaders from the Centers for Medicare & Medicaid Services Center for Program Integrity, the Office of Counsel to the HHS Office of Inspector General (HHS-OIG), and the DOJ’s Civil Division, to proactively identify, investigate, and pursue healthcare fraud, especially where patient care and data integrity are at risk.
Going deeper
The new working group will prioritize enforcement in:
- Medicare Advantage fraud.
- Drug/device pricing manipulation (rebates, discounts, formulary placement).
- Network adequacy violations (barriers to care).
- Kickbacks involving federally paid medical goods.
- Use of defective medical devices impacting safety.
- Electronic health record (EHR) misuse to increase billing.
Companies using EHRs and patient data to drive revenue, especially in ways that involve overutilization, will be scrutinized. HIPAA-covered entities that manipulate digital systems risk False Claims Act liability and potential HIPAA violations if protected health information (PHI) is misused or disclosed improperly.
What was said
“The DOJ-HHS False Claims Act Working Group encourages whistleblowers to identify and report violations of the federal False Claims Act involving priority enforcement areas. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to HHS at 800-HHS-TIPS (800-447-8477),” explains the Group.
By the numbers
- $2.9 billion recovered by the DOJ in civil fraud and false claims cases for FY ending September 30, 2024.
- 3x the government’s losses, plus additional civil penalties under the False Claims Act for each violation, adjusted for inflation.
- 6 top focus areas identified in this new enforcement initiative.
Why it matters
This joint effort shows that the government is intensifying its oversight of healthcare fraud and regulatory noncompliance. Healthcare organizations, especially those handling sensitive billing or health data, must review their compliance policies, data handling practices, and vendor relationships.
This is especially true where EHR systems are used for billing optimization. If those systems are manipulated to generate unwarranted reimbursement claims, that behavior may now fall under heightened scrutiny, and if PHI is involved, it raises HIPAA compliance concerns.
Related: HIPAA Compliant Email: The Definitive Guide
FAQs
What is a kickback in healthcare?
Any form of compensation offered or received to influence the referral or use of services/items covered by federal healthcare programs.
Is failing to repay government funds also a false claim?
Yes, knowingly retaining overpayments or avoiding obligations can trigger False Claims Act (FCA) liability.
Can whistleblowers report fraud under the FCA?
Yes, individuals can file qui tam lawsuits and may receive a portion of recovered funds.
Kirsten Peremore : Aug 27, 2025 4:59:45 AM
