As we don our green attire and raise a glass to St. Patrick’s Day, it’s worth pondering what luck—or lack thereof—a second Trump administration might bring for healthcare providers. While some may hope for the four-leaf clover of regulatory relief, history suggests that enforcement against healthcare fraud will remain as aggressive as ever. The Trump administration may embrace deregulation, but when it comes to fraudulent billing and financial misconduct, the watchdogs won’t be taking a holiday. Health care fraud is an a-political topic. It doesn’t matter who is in office.
Much like the enduring traditions of St. Patrick’s Day, fraud enforcement remains a constant, regardless of political shifts. The numbers tell the tale: civil fraud enforcement recoveries and whistleblower lawsuits have remained steady across multiple administrations. The Department of Justice (DOJ) and the Health and Human Services Office of Inspector General (HHS-OIG) continue to crack down on fraudulent activities, with the Health Care Fraud Prevention and Enforcement Action Team strike force—established in 2009—still going strong.
For providers, this means that while there may be fewer regulatory hoops to jump through, the scrutiny of fraud investigations won’t wane. False Claims Act (FCA) lawsuits and whistleblower actions are expected to surge, particularly concerning pandemic-era billing practices. Just as St. Patrick’s Day revelers can expect a steady stream of festivities, providers should prepare for an ongoing wave of fraud enforcement actions.
COVID-19’s legal legacy remains ever-present. Fraud investigators continue to examine providers that exploited pandemic-related regulatory flexibilities. A prime example is Renew Health Group, which settled for over $7 million last year amid allegations of improperly billing Medicare for patients who had no acute illness but had merely been exposed to COVID-19.
The COVID-19 Fraud Enforcement Task Force has been particularly zealous, bringing more than 3,500 criminal cases and securing over $1.4 billion in forfeitures. Providers have faced allegations ranging from improper billing for testing supplies to misusing relief funds. More than 600 whistleblowers have come forward in such cases, resulting in settlements surpassing $100 million. In other words, much like the persistence of St. Patrick’s Day parades, the government’s fraud-fighting efforts show no signs of stopping.
Even as enforcement agencies remain vigilant, the judiciary has emerged as a potential ally for providers. In 2024, several key court decisions cast doubt on long-standing legal precedents that have historically favored the government in FCA and regulatory enforcement cases.
One significant case, Zafirov, challenged the constitutionality of whistleblower-led FCA lawsuits, arguing that they essentially allow private citizens to act as government officers. If upheld on appeal, this ruling could dramatically limit the ability of whistleblowers to file FCA cases, offering providers a reprieve from these often-costly legal battles. This could be the pot of gold at the end of the rainbow for many providers weary of qui tam lawsuits.
Meanwhile, the Supreme Court’s ruling in Loper Bright Enterprises v. Raimondo has disrupted the traditional judicial deference to regulatory agencies, potentially giving providers stronger grounds to challenge CMS regulations. This shift could weaken federal oversight in certain areas, much like how St. Patrick drove the snakes out of Ireland—or so the legend goes.
Additionally, SEC v. Jarkesy brought a pivotal ruling, with the Supreme Court finding that civil penalties imposed by administrative agencies without a jury trial were unconstitutional. This decision may have major implications for providers facing CMS-imposed civil monetary penalties. Legal experts suggest that pending cases before the HHS Departmental Appeals Board may be the first to apply Jarkesy to CMS enforcement actions.
Looking forward, the regulatory environment in 2025 is poised to be a mixed bag—perhaps as unpredictable as finding a genuine four-leaf clover.
Looking forward, the regulatory environment in 2025 is poised to be a mixed bag—perhaps as unpredictable as finding a genuine four-leaf clover. On one hand, a second Trump administration might aggressively pursue deregulation and roll back certain CMS requirements, giving providers some breathing room. On the other hand, enforcement agencies remain as steadfast as ever in their commitment to curbing fraud, ensuring that qui tam lawsuits, DOJ investigations, and criminal enforcement actions remain in full swing.
As healthcare providers navigate these uncertain times, perhaps they should take a cue from St. Patrick’s Day: hope for the luck of the Irish, but be prepared for the challenges ahead. Because whether it’s green beer or green in the form of government funds, federal oversight isn’t going away anytime soon.
“Saint Patrick was a gentleman, who through strategy and stealth, drove all the snakes from Ireland, here’s a toast to his health. But not too many toasts, lest you lose yourself and then forget the good Saint Patrick and see all those snakes again.” — Unknown