On May 12, 2025, the United States Department of Justice’s (“DOJ”) Criminal Division released a major policy memorandum outlining its enforcement priorities for the upcoming year. Unsurprisingly, the number one priority for the Division was investigating and prosecuting white-collar crimes related to waste, fraud, and abuse—and particularly healthcare fraud. This emphasis on prosecuting healthcare fraud reflects the current administration’s broader goals of eliminating waste in federal programs, such as Medicare, Medicaid, and TRICARE, and ensuring that taxpayer dollars are used efficiently and effectively.
Continuation of the First Trump Era’s Enforcement Strategy
President Trump’s second administration is expected to maintain its strong enforcement posture in the healthcare space. During President Trump’s first term, healthcare fraud remained a key focus, with both criminal and civil investigations increasing compared to the final years of the Obama administration. In 2018, criminal healthcare investigations rose by 17 percent and stayed steady through 2020. In fact, the Trump administration brought the two largest healthcare fraud cases in U.S. history, charging hundreds of defendants and citing billions in losses.
Building on that legacy, the Criminal Division’s Healthcare Fraud Unit under this administration is growing, with additional trial attorneys being reassigned to the unit from areas with shifting enforcement priorities, such as the Foreign Corrupt Practices Act unit. Moreover, the DOJ has announced plans to establish a “Medicare and Medicaid fraud prosecution program” in fifteen U.S. Attorney’s Offices. This program is designed to address fraud by nonresidents and others who illegally receive benefits, with a particular focus on fraudulent durable medical equipment billing schemes.
Key Areas of Criminal Healthcare Enforcement in 2025
Emphasis on Prosecuting Medicare, Medicaid, and TRICARE fraud. Across administrations the DOJ has maintained a consistent focus on prosecuting fraudulent schemes that compromise the integrity of Medicare, Medicaid, and TRICARE. That said, the recent policy statement from the DOJ signals an even greater emphasis on rooting out fraud within federal healthcare programs. As a result, companies can expect to see a continued—and likely expanded—emphasis on cases involving fraudulent billing practices, especially those targeting vulnerable patient populations and involving the misuse of federal healthcare funds. These prosecutions may align with other white collar priorities recently announced by DOJ, such as combating complex money laundering schemes and fraud schemes that threaten the health and safety of consumers. Civil enforcement under the False Claims Act will also continue to play an important role in the government’s pursuit of health care fraud.
Continued Focus on Kickback Violations.The Anti-Kickback Statute (AKS) continues to be a “go to” statute for prosecutors, in part due to its relatively straightforward prohibition of paying or receiving bribes to generate business for a provider. While not all AKS violations are pursued criminally, since some are brought civilly under the False Claims Act, individuals at the center of these schemes continue to face significant criminal exposure, especially when it comes to improper physician compensation arrangements, referral networks, and financial relationships between medical practitioners and third parties.
Heightened Emphasis on Elder Fraud. As part of its May 6, 2025, policy memorandum, the DOJ emphasized its focus on pursuing cases related to elder fraud, in addition to cases related to healthcare fraud. The combination of these priorities suggests that the DOJ may place a heightened emphasis on pursuing cases against nursing homes that violate federal law, as such violations align with both its focus on protecting elderly populations and prosecuting healthcare-related offenses. Moreover, conduct that puts nursing home residents at greater risk may even result in the DOJ pursuing criminal charges against individuals.
Violations of the Controlled Substances Act (CSA) and the Food, Drug and Cosmetic Act (FDCA). The DOJ also identified CSA and FDCA violations as priorities, particularly with respect to the distribution of fentanyl and opioids. This administration is likely to maintain focus on drug-related prosecutions, especially given Attorney General Bondi’s background in prosecuting pill mills and opioid-related offenses. These prosecutions will likely focus on medical practitioners who unlawfully prescribe controlled substances, the distribution of misbranded or adulterated drugs, as well as fraudulent pain management clinics (which often serve as fronts for illegal prescribing and distribution of opioids). In terms of FDCA investigations and prosecutions, it is likely that many will align with the priorities and initiatives of the FDA, including the FDA’s focus on increased use of unannounced foreign inspections to identify bad actors in the drug and food industries.
Emerging Concerns over AI-Enabled Healthcare Fraud. Finally, as in most other areas of prosecution, the DOJ is likely to focus on the use of artificial intelligence to enable fraudulent conduct. The rapid emergence of AI allows medical practitioners to streamline operations such as billing, documentation, and even patient communications. Some medical practitioners may take advantage of these services to exacerbate existing fraud schemes such as boilerplate record fraud, phantom invoicing, or identity theft. As AI continues to evolve, the DOJ will likely develop new legal theories to combat these fraudulent acts.
Whistleblowers and Their Role in Healthcare Fraud Detection
The use of whistleblowers to uncover violations of healthcare fraud will likely continue into the second Trump administration. Notably, there appears to be a growing interest from the DOJ to leverage whistleblower reports to identify systemic fraud schemes within private insurers that may resemble fraud schemes against federal programs. As a result, whistleblowers may play an increasingly critical role in exposing fraudulent healthcare schemes, potentially leading to heightened scrutiny and legal and financial exposure for private healthcare companies and insurers.
Healthcare Companies May Face Greater Risks for Failing to Self-Disclose Criminal Violations
In tandem with its May 12 policy memorandum, Matthew Galeotti, head of the DOJ Criminal Division, also announced a revised Corporate Enforcement and Voluntary Self-Disclosure Policy (CEP) aimed at providing clearer incentives for companies to self-disclose misconduct by offering a more direct path to declinations and reduced penalties. The revised policy includes declinations for voluntary self-disclosure, full cooperation, and remediation. Because of this clearer path to declination, the DOJ may take an aggressive prosecutorial stance against companies that identify potential criminal violations but fail to self-disclose those violations.Accordingly, healthcare companies should carefully assess the legal risks of failing to self-report violations when evaluating their exposure to investigation and prosecution by DOJ. While this revised policy comes from the head of the DOJ’s Criminal Division and is focused on criminal enforcement, civil False Claims Act prosecutors will typically follow the spirit of the Criminal Division’s self-disclosure policies.
Takeaways for Healthcare Companies
Despite the changing enforcement priorities of the Trump administration, the one thing that is likely to remain constant is the DOJ’s focus on investigating and prosecuting healthcare fraud cases. To avoid becoming targets of federal enforcement matters, healthcare companies and providers should consider enacting proactive compliance and risk mitigation measures such as:
- Strengthening Compliance Programs: Maintain compliance with applicable healthcare laws through auditing and monitoring and by establishing clear policies, procedures, and training programs.
- Knowing Your Partners: Be cognizant of who you are contracting with and the risks that may entail. Healthcare organizations should also ensure that they are scrutinizing their third-party relationships to ensure compliance with laws governing healthcare arrangements.
- Staying Ahead of the Trends: Actively monitor DOJ enforcement actions, settlements, and statements to anticipate areas of increased scrutiny and update compliance programs to address any emerging risks.
McGuireWoods is nationally recognized for its healthcare counseling and enforcement capabilities. The team is comprised of former high-level federal prosecutors that are experienced at managing every stage of complex investigations and have extensive experience helping clients navigate the intricacies of healthcare laws both criminal and civil. Please reach out to us if we can assist you in any manner.