Good News for Health Care Fraud Whistleblowers

The New False Claims Act Working Group

In a sweeping effort to crack down on health care fraud, the U.S. Department of Justice (DOJ) and the Department of Health and Human Services (HHS) announced two major developments this month: the largest health care fraud enforcement action in U.S. history and the creation of a new False Claims Act (FCA) Working Group. Together, the initiatives signal a new era of aggressive enforcement of the FCA against health care providers and companies that submit false claims to Medicare, Medicaid, and other government health care programs.

The latest development is a joint DOJ-HHS FCA Working Group that will expand their collaboration in civil enforcement of health care fraud and setting new priority areas for future investigations. 

Just days earlier, DOJ revealed the results of a massive health care fraud takedown, dubbed “Operation Gold Rush,” charging 324 individuals and alleging more than $14 billion in fraud.
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“These announcements make one thing clear: the government is intensifying its efforts to identify, punish, and prevent fraud against federal health care programs,” said one health law expert. “Companies in this space need to treat compliance as a mission-critical function.”

​A New Partnership to Combat Health Care Fraud

The DOJ-HHS FCA Working Group marks a formalized, cross-agency collaboration between DOJ’s Civil Division, the HHS Office of General Counsel, the Office of Inspector General (OIG), the Centers for Medicare & Medicaid Services (CMS), and U.S. Attorneys' offices nationwide. Its goal is to enhance enforcement under the FCA, a powerful statute that allows the government—and whistleblowers acting on its behalf—to recover funds fraudulently obtained from federal programs.

This new structure is designed to streamline civil investigations, generate new leads through data mining, and quickly assess the merit of whistleblower cases. The Working Group will also help HHS determine when to suspend Medicare payments or when DOJ should move to dismiss weak or meritless whistleblower complaints—a tool rarely used in the past but now gaining traction.
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Priority enforcement areas include:

• Medicare Advantage fraud, including upcoding and inflated diagnoses;
• Drug and device pricing schemes, including kickbacks disguised as discounts or rebates;
• Patient access barriers, such as violations of network adequacy requirements;
• Kickback arrangements involving medical devices, durable equipment, and pharmaceuticals;
• Defective medical devices that endanger patient safety;
• Manipulation of electronic health records (EHRs) to support improper billing.

​“The focus on Medicare Advantage and EHR manipulation reflects how enforcement is adapting to the current health care landscape,” said one compliance officer. “This isn’t business as usual.”

Largest Health Care Fraud Takedown in History

Parallel to the formation of the Working Group, DOJ’s Criminal Division launched its most extensive health care fraud takedown to date. The coordinated sweep charged hundreds of individuals and institutions across multiple states and international jurisdictions, and exposed elaborate schemes that ranged from telehealth fraud to high-tech scams using artificial intelligence and cryptocurrency.

Among the most notable allegations:

• Four defendants from Pakistan were charged in a $703 million telemedicine scheme using AI-generated patient consults.
• Twelve individuals, including Russian agents, were charged in a $10.6 billion transnational scheme involving encrypted messaging, fake corporate entities, and fraudulent billing across three countries.
• A hospital was held civilly liable for allegedly failing to inform heart transplant patients about their conditions.
• Skilled nursing facilities agreed to pay over $6 million for omitting “related party” transactions in cost reports.
• A lab owner and staff were charged for offering gift cards to substance abuse patients as kickbacks.

​“These cases go far beyond traditional billing fraud,” said DOJ officials. “They show how health care fraud is evolving—and how our enforcement is evolving with it.

A Renewed Role for Whistleblowers

Whistleblowers remain central to the government’s FCA strategy. Under the law, individuals who report fraud can receive a share of the government’s recovery—often totaling millions of dollars. The DOJ-HHS announcement even includes a specific call for more qui tam filings, indicating a renewed push for insider information.

Taken together, the DOJ-HHS Working Group and the 2025 Health Care Fraud Takedown signal an unprecedented level of coordination and enforcement in the health care space. For providers, insurers, and manufacturers, the stakes are higher than ever.

“This is not a one-off operation,” warned a former federal prosecutor. “This is a systemic shift in how the government is policing health care fraud. Companies that fail to adapt are putting themselves in the crosshairs.”

With the DOJ and HHS leveraging cutting-edge technology, cross-border resources, and renewed legal firepower, the era of “reactive compliance” may be over. Health care fraud whistleblowers should take advantage of what likely will be a transformative decade of enforcement.

Consult an Experienced Whistleblower Lawyer

If you have evidence that a health care provider or organization is submitting false claims to Medicare, Medicaid, or other government health care programs, you should contact an experienced whistleblower lawyer immediately.  You may be entitled to legal protections and a financial reward. 

Call John Howley, Esq. today at 212-601-2728 to schedule a free and confidential consultation.