The Department of Justice and the Department of Health and Human Services announced a revived collaboration in July 2025 between the two agencies: the False Claims Act Working Group. The FCA Working Group focuses on combatting healthcare fraud through the use of FCA enforcement. With its relaunch, the group will be focusing on new areas of healthcare fraud and increasing scrutiny on others.
This article by
TELG principal Janel Quinn and TELG associate Keri Teal was published by The Employment Law Group, P.C. on September 11, 2025.
DOJ & HHS Relaunch FCA Working Group With New Healthcare Fraud Priorities
By Janel Quinn and Keri Teal
The U.S federal government reinforced its commitment to combatting healthcare fraud with the relaunch of the False Claims Act Working Group. The group — a collaborative effort between the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) — revealed its new priorities in a July 2, 2025 press release.
The FCA Working Group was previously formed toward the end of President Donald Trump’s first term in December of 2020. While several enforcement priorities are longstanding, the group’s revival brings new areas into focus that will drive its strategies under Trump’s second term.
What’s New in Enforcement Priorities
The False Claims Act (FCA) is a federal law making it illegal to lie or deceive the government in an attempt to claim more money. The FCA Working Group identifies barriers to accessible care — such as network adequacy violations, which occur when insurance plans fail to provide a wide enough network of care providers to meet enrollee care needs — as an area of heightened enforcement focus.
What’s Receiving Renewed Attention
Of the already existing areas of focus, the Working Group’s investigators will be turning a keener eye toward fraud involving:
- Medicare Advantage billing and coding practices that are improperly used to inflate reimbursements paid out to Medicare Advantage Organizations;
- Drug, device, and biologic pricing, such as misreported rebates, discounts, and formulary placements;
- Kickback schemes tied to pharmaceuticals, devices, or durable medical equipment;
- Improperly marketed or defective medical devices that pose safety risks; and
- Manipulation of Electronic Health Records (EHRs), including the use of automatic templates or auto-population features, to bill for more services than are actually rendered
The emphasis on EHR manipulation and network adequacy violations marks a shift toward targeting modern, data-driven fraud schemes. These issues increasingly arise where billing systems and vendor tools are used to inflate reimbursements, often without clear clinical justification.
Why These Areas Matter
As succinctly stated in the DOJ’s press release: “Healthcare fraud and abuse depletes taxpayer funds, corrodes public health and safety, and undermines the integrity of the federal healthcare system.” The Working Group’s new focuses and strategies under the umbrella of healthcare fraud may have the most impact on taxpayers and federal funds for a variety of reasons:
- High-dollar costs: Medicare Advantage and specialty drugs or devices cost enormous amounts of money for the U.S. government, making fraud in these areas especially damaging to taxpayers and federal health care programs that are already shelling out a lot of money for justifiable claims — let alone fraudulent claims.
- Risk of systemic abuse: EHR template misuse or improper coding can become unofficial norms in the healthcare industry, turning physician workflows into consistent sources of overbilling.
- Greater detection and accountability: The DOJ’s use of advanced data analytics and inter-agency coordination have the potential to identify fraud patterns more swiftly, reducing the window in which harmful and/or costly schemes can persist.
A Real World Example
The DOJ’s recent $98 million settlement with Independent Health Association illustrates the type of conduct now in the government’s crosshairs.
The Medicare Advantage provider allegedly submitted diagnoses over a period of seven years that were unsupported by medical records to the Centers for Medicare & Medicaid Services (CMS). According to the DOJ, Independent Health failed to validate diagnosis data from a third-party vendor even after internal reviews raised concerns.
Independent Health received an improperly high amount of Medicare payments as a result, and risk scores — used by the CMS to determine healthcare costs — were skewed.
Validating diagnosis data is critical because Medicare Advantage payments are risk-adjusted, meaning CMS pays more to providers for patients with more severe or complex health conditions. If diagnosis codes are not accurate and supported by medical records, plans may receive inflated payments they aren’t entitled to. Further, skewed risk scores not only overcharge federal health care programs and taxpayers but also distort patient profiles, potentially affecting care management and resource allocation.
This type of risk-adjustment manipulation, combined with a lack of meaningful chart review and oversight, is exactly the scenario the Working Group intends to prioritize. The whistleblower in the case, a former risk adjustment manager, received over $22 million for his role in exposing the fraud, emphasizing the government’s commitment and the potential rewards for insiders who come forward.
If you discover that your employer is engaging in similar schemes or have a problem at work more generally, call The Employment Law Group.
