DOJ Fraud Section 2025 Report on Healthcare Fraud

In fiscal year 2025, the U.S. Department of Justice (DOJ) Fraud Section reported that False Claims Act settlements and judgments exceeded $6.8 billion, with more than $5.7 billion related to healthcare matters. A key feature of DOJ’s enforcement approach was the use of advanced data analytics and proactive detection tools to identify billing outliers and anomalous claims patterns that led to investigations.

The DOJ highlighted as a major accomplishment its leadership of a coordinated National Health Care Fraud Takedown, which resulted in charges against 324 defendants across 50 federal districts, including 96 licensed medical professionals, with approximately $14.6 billion in intended losses. The takedown involved extensive multi‑agency cooperation among the DOJ Fraud Section Health Care Fraud Unit, U.S. Attorneys’ Offices, HHS‑OIG, FBI, DEA, CMS, and state partners. The takedown spanned 50 federal districts and 12 state attorneys general offices. As part of the enforcement actions, law enforcement seized over $245 million in cash, vehicles, cryptocurrency and other assets. In addition, CMS reported preventing over $4 billion in improper payments and suspended or revoked billing privileges for 205 providers in the lead‑up to the takedown. The DOJ identified several major areas of current enforcement focus, including durable medical equipment (DME), wound care services, opioid diversion/illegal prescribing, marketing/beneficiary‑data misuse, third‑party marketers, referral networks, and high‑volume billers.

Compliance Officer Tips

1. Tighten DME and telemedicine controls (vendor onboarding, identity verification, and order/physician‑order validation.)
2. Monitor billing outliers to identify anomalous claims.
3. Strengthen beneficiary consent/recording controls.
4. Conduct risk assessments of DME, telehealth, wound care, pharmacy, and lab services.
5. Audit claims for billing outliers and unusual referral patterns.
6. Enhance vendor onboarding, identity verification, and ongoing due diligence for suppliers, marketers, and telehealth partners.
7. Conduct medical‑necessity review, and physician‑order validation processes.

For more information on this topic contact Richard Kusserow at [email protected].

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 3,000 health care organizations and entities in developing, implementing and assessing compliance programs.