The U.S. Department of Health and Human Services (HHS) and the Department of Justice (DOJ) have jointly announced the launch of a reinvigorated DOJ-HHS False Claims Act Working Group aimed at enhancing interagency coordination around key fraud enforcement priorities in the healthcare space. This initiative underscores the federal government’s ongoing reliance on the False Claims Act (FCA) as its most powerful civil enforcement mechanism to address fraud involving federal healthcare programs.
The FCA imposes liability on individuals and entities that knowingly submit, or cause the submission of, false or fraudulent claims for payment to the United States. It also includes qui tam provisions that empower whistleblowers to bring actions on the government’s behalf and share in any recovery.
The Working Group will consist of leadership from the HHS Office of General Counsel, the CMS Center for Program Integrity, the Office of Counsel to the HHS Office of Inspector General (HHS-OIG), and DOJ’s Civil Division, with representation from U.S. Attorneys’ Offices nationwide. It is co-led by the HHS General Counsel, the Chief Counsel to HHS-OIG, and DOJ’s Deputy Assistant Attorney General for the Commercial Litigation Branch.
As part of its work, the Working Group will prioritize:
- Medicare Advantage risk adjustment fraud and upcoding
- Improper manufacturer arrangements involving pricing, rebates, formulary placement, and reporting obligations
- Violations impacting network adequacy and patient access
- Anti-kickback violations involving drugs, medical devices, and other federally reimbursed products
- Use of defective medical devices that compromise patient safety
- Electronic Health Records (EHR) manipulation to generate inflated utilization or misrepresent clinical documentation
In addition to coordinating referrals and investigative resources, the Working Group aims to enhance the use of data analytics, leverage HHS-OIG report findings, and accelerate parallel civil enforcement efforts. It will also evaluate use of CMS payment suspensions and DOJ dismissals of qui tam complaints where appropriate, consistent with policy guidance in the Justice Manual.
For healthcare organizations, this announcement signals increased scrutiny in high-risk reimbursement categories, particularly risk-bearing arrangements, digital health platforms, and third-party vendor relationships. Providers, compliance officers, legal counsel, and billing professionals should ensure that internal audit protocols and vendor oversight mechanisms are robust and defensible.
Read the full DOJ-HHS Press Release here.