The Department of Justice and Department of Health and Human Services are coordinating aggressive enforcement against companies defrauding federal healthcare programs through the DOJ-HHS False Claims Act Working Group. This collaborative effort strengthens pursuit of healthcare fraud across multiple high-risk sectors. For healthcare workers and industry insiders who witness fraud, understanding these priority enforcement areas is critical—the government is actively seeking information and allocating substantial resources to these investigations.
Why These Priorities Matter
Healthcare fraud drains billions in taxpayer dollars annually and compromises patient safety. By uniting leadership from DOJ's Civil Division, HHS Office of General Counsel, Centers for Medicare & Medicaid Services, and the HHS Office of Inspector General, this working group coordinates an aggressive approach to pursuing fraudulent actors across specific high-risk areas where enforcement is concentrated.
Priority Enforcement Areas: Where the Government Is Looking
The working group has identified six priority enforcement areas representing the highest-risk sectors for fraud:
Medicare Advantage: Fraud in this rapidly growing program, including risk adjustment manipulation, upcoding diagnoses, and billing for services never rendered.
Drug, Device, and Biologics Pricing: Schemes involving discounts, rebates, service fees, formulary placement arrangements, and false price reporting that inflate costs to federal programs.
Barriers to Patient Access: Violations of network adequacy requirements that prevent patients from receiving timely care while companies continue collecting government payments.
Kickbacks: Illegal arrangements involving drugs, medical devices, durable medical equipment (DME), and other products paid by federal healthcare programs, including payments to physicians or pharmacies for referrals or prescriptions.
Defective Medical Devices: Materially defective devices that compromise patient safety yet continue being billed to Medicare and Medicaid.
Electronic Health Records Manipulation: Tampering with EHR systems to generate inappropriate utilization of Medicare-covered products and services, driving unnecessary billing.
What This Means for Whistleblowers
The working group explicitly encourages whistleblowers to report violations in these priority areas. When the government publicly announces enforcement priorities, it signals readiness to investigate, pursue cases aggressively, and allocate resources to these matters.
If you work in healthcare and have witnessed fraud in any priority area, your information could be invaluable. Under the False Claims Act's qui tam provisions, whistleblowers can file lawsuits on behalf of the government and receive 15-30% of recovered funds. Given that False Claims Act recoveries regularly reach hundreds of millions or even billions of dollars, whistleblower awards can be substantial.
The working group's coordinated approach includes enhanced cross-agency collaboration, improved data mining capabilities, and streamlined investigation procedures for faster case processing.
Protected and Rewarded
Federal law protects whistleblowers from retaliation. If you report fraud and face termination, demotion, harassment, or other adverse actions, you have legal remedies including reinstatement, double back pay, and compensation for damages.
Take Action
If you have knowledge of healthcare fraud in these priority areas, the government wants to hear from you—and this may be your opportunity to make a difference while securing significant financial compensation. Whistleblower cases require experienced legal guidance to navigate complex procedures and maximize your protection and recovery.
Contact us for a confidential consultation to discuss your case and learn how we can help you come forward safely and effectively.
