DOJ Launches More Aggressive Healthcare Fraud Enforcement

On May 27, 2026, the U.S. Department of Justice (DOJ) issued new guidance for more aggressive enforcement of fraud involving healthcare providers, insurers, managed care organizations, and vendors participating in federal programs. Prosecutors are directed to prioritize qui tam (whistleblower) fraud complaints, particularly those involving Medicare and Medicaid. The DOJ plans to accelerate its initial review of these complaints within 60 to 120 days to rapidly identify “meritorious” cases. Enforcement resources will be channeled toward large-scale fraud schemes.

This announcement is another in a series of heightened enforcement actions with a message that whistleblower complaints will be given priority. As part of this initiative, the DOJ is also increasingly relying on data analytics, whistleblower incentives, interagency coordination, and specialized healthcare fraud strike forces. This comes at a time where the Centers for Medicare & Medicaid Services (CMS) is also intensifying program integrity efforts that have included a nationwide enrollment moratorium affecting certain hospice, home health, and durable medical equipment (DME) suppliers due to a high volume of fraud cases. The implications for health care organizations include: (a) internal complaints and hotline reports may now trigger government scrutiny much faster; (b)  delays in investigating or remediating potential billing issues can create greater risk; (c) documentation supporting coding, medical necessity, and diagnosis face heightened review; (d) Medicare Advantage risk adjustment practices will remain a major enforcement target; and (e) increased coordination among DOJ, the Office of Inspector General (OIG), CMS, and Medicaid Fraud Control Units (MFCUs).

10 Tips for Compliance Officers

1. Accelerate and properly document internal investigations
2. Verify effective ongoing compliance monitoring by program managers
3. Validate effective monitoring with an ongoing auditing program
4. Reassess False Claims Act (FCA) response protocols
5. Review whistleblower retaliation protections
6. Verify effectiveness of compliance reporting systems (e.g., hotline)
7. Review all arrangements with potential referral sources
8. Review effectiveness of the claims processing quality assurance program
9. Validate that self-disclosure and voluntary overpayment policies are functioning properly
10. Engage a Compliance Program Effectiveness Evaluation to strengthen the program

Interested in learning how the current regulatory environment can affect your compliance program? Richard Kusserow can be reached at [email protected] to discuss support for your program.

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.