The DOJ’s New National Fraud Enforcement Division Priorities

The new Department of Justice (DOJ) National Fraud Enforcement Division (NFED) has a staff of more than 500 attorneys dedicated to a more coordinated, aggressive, and data-driven approach to fraud enforcement. Priority is being given to healthcare because of the size of federal healthcare spending and the vulnerability of beneficiaries who rely on Medicare, Medicaid, and other public programs. Particularly cited areas include fraud involving telemedicine schemes, home health and hospice services, improper prescribing and dispensing of controlled substances, and deceptive marketing of healthcare products and services.

For providers, suppliers, telehealth companies, home health agencies, hospices, laboratories, and pharmacies, the message is clear: enforcement activity is likely to become more coordinated, analytics-driven, and focused on patterns that suggest billing abuse, medical necessity concerns, improper referrals, or weak oversight. By combining expanded personnel, national coordination, and data-driven enforcement, the NFED aims to identify fraud indicators earlier and pursue matters more systematically.

The increasing use of data analytics means that anomalies may be identified more quickly than in prior enforcement cycles. Outlier billing patterns, unusually high utilization, insufficient documentation, questionable referral relationships, or repeated coding inconsistencies can attract attention even before a whistleblower complaint or formal audit occurs. These enforcement developments should serve as a wake-up call for compliance officers to address issues identified by the DOJ before enforcement authorities come knocking at the door.

10 Suggested Compliance Officer Tips

1. Reassess the compliance program now—before external inquiries begin.
2. Conduct, or arrange for, a risk assessment to identify and address compliance weaknesses.
3. Confirm that ongoing monitoring by operational leaders is active in identifying and addressing risks.
4. Implement ongoing compliance auditing to independently test, verify, and validate monitoring results.
5. Review high-risk service lines to ensure documentation supports medical necessity.
6. Evaluate controls in home health, hospice, pharmacy, controlled substance, laboratory, and other DOJ-priority areas.
7. Review and update telehealth policies.
8. Assess physician arrangements, referral relationships, and marketing practices for compliance with applicable fraud and abuse laws.
9. Review billing and coding documentation for accuracy.
10. Consider engaging an independent compliance program effectiveness assessment.

For more information on this topic, please contact Richard Kusserow ([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.