It is well known that the Department of Justice (DOJ) under President Trump has prioritized criminal investigations targeting actors who profit through “waste, fraud, and abuse.” In May, Matthew R. Galeotti, the Head of the DOJ’s Criminal Division, announced the DOJ’s first-ever White-Collar Enforcement Plan (the “Plan”), which directs federal prosecutors to focus on specific priority enforcement areas, including several that directly impact the healthcare industry.

While the Plan generally reflects a more measured approach to white-collar criminal law enforcement, it places particular emphasis on investigating and prosecuting healthcare fraud. Individuals who work in the healthcare industry should be aware that:

• Investigating and prosecuting healthcare violations continues to dominate the enforcement list for the DOJ’s Criminal Division.
• The DOJ has expanded the types of reports eligible under its Corporate Whistleblower Awards Program to include information about potential violations involving public healthcare benefit programs.
• While the DOJ has signalled reduced reliance on corporate compliance monitors, healthcare providers may still be subject to compliance monitoring and requirements imposed by the Office of the Inspector General for the US Department of Health and Human Services (“HHS-OIG”) and other regulators.

Examples of Healthcare Fraud Targeted by the DOJ

For individuals and companies in the healthcare sector, the DOJ’s prioritization of investigating healthcare fraud is likely to result in the increased targeting of questionable or fraudulent activities committed by healthcare providers, home healthcare agencies, patients, and other individuals, particularly those involving federal and private insurance programs.

Fraud Committed by Healthcare Providers

• Examples of healthcare fraud committed by providers include:
• Double-billing - submitting multiple claims for the same service
• Phantom billing - billing for supplies or a service that a patient never received
• Unbundling - submitting multiple bills for the same service
• Upcoding - billing for a more expensive service than the patient actually received
• Kickbacks + Referral Fees - providers are prohibited under the Anti-Kickback statutes from making payments to persons or entities for the referral of patients or services

Fraud Committed by Patients and Other Healthcare Consumers

Fraud committed by patients and other healthcare consumers can include:

• False marketing - convincing people to share their health insurance information to bill for services that were never provided or to enroll them in a fake benefit plan
• Identity theft - fraudulently using another person’s health insurance
• Impersonating a healthcare professional - providing or billing for health services or equipment without a license
• Receiving Kickbacks for the referral of patients or services - under the Anti-Kickback statutes individuals are prohibited from receiving payment for the referral of patients or services

Prescription Fraud

Common examples of prescription fraud include:

• Forgery - creating or using forged prescriptions.
• Diversion - using legal prescriptions for illegal purposes, such as selling prescription medications.
• Doctor shopping - visiting multiple healthcare providers to obtain prescriptions for controlled substances, or obtaining prescriptions from providers that engage in unethical practices.

Anticipated Changes to the Investigation and Reporting of Healthcare Fraud

The White-Collar Enforcement Plan identified three significant changes to how the DOJ’s Criminal Division will investigate and prosecute cases of healthcare fraud.

Expanding the DOJ’s Whistleblower Program

The DOJ’s Whistleblower Program was launched in August 2024 and provided whistleblowers with a new way to report healthcare violations that were not covered under the False Claims Act. The DOJ’s revised 2025 guidance extends qualifying reports to include tips related to healthcare fraud involving public healthcare programs and announced that “fraud against patients, investors, and other non-governmental entities in the healthcare industry” may qualify for recovery.

Additional Incentives for Voluntary Self-Disclosure

Under the 2025 Plan, companies that meet the requirements for self-disclosure, remediation, and cooperation will be entitled to a non-prosecution agreement (NPA), rather than a presumption of receiving one. Companies considering self-disclosure should be prepared to meet the DOJ’s heightened expectations regarding the extent of cooperation in order to receive an NPA.

Reduced Reliance on Corporate Compliance Monitors

Mr. Galeotti announced that healthcare providers can expect to see fewer compliance monitors in criminal cases, which could decrease the likelihood that a company will have a monitor imposed as part of a criminal resolution. However, this change will not impact monitoring and reporting requirements imposed by other regulators.

Why Healthcare Providers Need Legal Guidance

The DOJ’s decision to prioritize targeting healthcare fraud means providers must carefully scrutinize business practices to avoid being caught up in a federal criminal investigation. If you suspect your business is being investigated for federal healthcare fraud, you will benefit from working with an experienced federal healthcare fraud defense attorney.

Hope Lefeber has over three decades of experience defending people charged with white-collar federal crimes, including healthcare fraud. She will develop a comprehensive strategy to minimize the likelihood of being charged with healthcare fraud and obtain superior results. When necessary, Ms. Lefeber will work with a team of highly qualified experts to investigate and prepare for trial.

Contact Experienced Healthcare Fraud Defense Attorney Hope Lefeber

If you are under investigation or have been charged with healthcare fraud, you need a defense lawyer who is skilled in defending against these charges. Contact the federal defense law office of Hope Lefeber today. Consultations are free and confidential.