Patrick Queenan
Federal law enforcement of criminal violations of health care-related fraud, waste and abuse is likely to increase this year.
Despite the many reports that the Department of Justice (DOJ) is facing costcutting measures and forcing depletion from the Department of Government Efficiency (DOGE) and that DOJ is shifting white-collar criminal enforcement priorities, the ranks of agents and prosecutors handling health care matters is likely growing.
That means more search warrants, subpoenas, target letters, indictments and law enforcement action from FBI, HHSOIG, DEA and other federal agencies.
DOJ under the Trump administration has been vocal in announcing how it will prioritize criminal cases involving immigration, violent crime and cartel-related drug trafficking. As a result, DOJ is shifting resources away from criminal cases involving public corruption, foreign corrupt practices and “kleptocracy” initiatives to other areas.
Given the administration’s focus on deterring fraud, waste and abuse, DOJ will likely refocus its resources to investigate and charge health care fraud in federal programs. Indeed, Medicare and Medicaid programs (as well as other federal health care benefit programs) spend over a $1 trillion a year paying claims. And federal criminal prosecutions and investigations related to fraud, waste and abuse on the programs return money to the public fisc. More prosecutions and investigations mean more money returned to the government.
Scott Armstrong
The FBI, HHS-OIG, DEA and other law enforcement agencies partner with prosecutors at the Fraud Section’s Healthcare Fraud Unit, as well as with U.S. Attorney’s offices all over the country to investigate and charge health care fraud, wire fraud, anti-kickback violations, unlawful prescribing and other criminal offenses related to the delivery of medical services.
Over recent years, federal law enforcement agencies have targeted the owners and operators of call centers contacting Medicare and Medicaid beneficiaries, laboratories conducting genetic testing, durable medical equipment companies, sober homes, telehealth companies, addiction treatment facilities, behavioral health providers and licensed practitioners (many of which were moonlighting with online or telehealth entities).
More recently, federal agencies have also opened criminal investigations into the distribution/prescribing of ketamine and amphetamines, fraud schemes involving enrollment in insurance plans, and the submission of claims for DME, genetic testing, prescription drugs and other medical services or products.
As a result, federal prosecutors have investigated and charged the owners of for-profit health care companies, investors, billers, patient brokers, providers and other medical professionals. These cases often involve charges under federal conspiracy law, which yield extensive, nationwide investigations that impact all aspects of the industry and can implicate companies and individuals that are situated far afield from the actual criminal conduct.
These investigations also collect evidence through the use of email, cellphone and premise search warrants, subpoenas for corporate and financial records, and other methods that often intrude upon the operations of innocent third-party entities.
The health care industry should expect sweeping law-enforcement initiatives to combat health care fraud in 2025. In addition, medical professionals should expect heightened inquiry and investigation from private insurance to combat the same. Navigating and handling the range of these inquiries requires skill and experience.
It is already a challenging time for health care providers and professionals, as insurance payors are increasing audit activity, reimbursement rates are stagnant, margins are thin, and fewer people are working in health care. If you or your entity find yourselves in the midst of an enforcement action or an investigation, there are ways to mitigate risk and avoid wasting valuable time and resources.
Patrick J. Queenan and Scott Armstrong are former federal prosecutors from the U.S. Department of Justice, Fraud Section, Healthcare Fraud Unit. Queenan is based at Sheehan Phinney working with Boston area and NH clients. Armstrong is at McGovern Weems PLLC in Washington, D.C., which defends health care providers, companies and individuals involved in federal criminal investigations and prosecutions in federal districts across the country.
