Health Care Fraud And Abuse Enforcement In 2026: Scale, Collaboration, And Expanding Risk Areas

The year ahead is likely to bring both continuity and escalation in the health care fraud and abuse landscape. Health care has been the largest driver of False Claims Act (FCA) recoveries for more than 20 years, and enforcement agencies show no signs of slowing.¹ Relators remain active, and federal and state enforcement authorities continue to prioritize program integrity. The result is an enforcement environment defined not only by volume, but also by scale: larger schemes, broader networks, and increasingly sophisticated investigative tools.

Recent nationwide takedown operations illustrate this shift. In the past two years, the Department of Justice (DOJ), the HHS Office of Inspector General (HHS-OIG), the Federal Bureau of Investigation (FBI), and state Medicaid Fraud Control Units have charged hundreds of defendants across dozens of districts, alleging billions in losses to federal programs.² These cases often involve sprawling operations, including multiple providers, marketing companies, telehealth platforms, and durable medical equipment (DME) suppliers all working together to generate high claim volumes quickly. Enforcement agencies are leveraging data analytics and cross-agency task forces to identify and dismantle fraud networks at scale.³

Telehealth, DME, genetic testing, and remote patient monitoring have been particular areas of focus. The rapid expansion of these services during and after the COVID-19 pandemic increased access but also opened opportunities for abuse when medical necessity documentation is weak or referral pathways are commercially driven.⁴ These cases often turn on the nature of key relationships, including how patients were identified, how providers were connected to suppliers, and whether remuneration influenced referral decisions. Wound care is another emerging focus. Because wound care often targets medically complex beneficiaries, overuse or questionable documentation draws attention quickly.

More traditional fraud and abuse risks remain firmly in play. The Anti-Kickback Statute and Stark Law continue to anchor enforcement in physician compensation, referral arrangements, and ancillary service use.⁵ Enforcement agencies remain focused on the substance of these relationships, not just formal compliance structures. Documentation of fair market value and commercial reasonableness remains important.

Medicare Advantage (MA) continues to be closely watched. As MA enrollment surpasses traditional Medicare, DOJ has intensified enforcement focused on risk-adjustment coding and the use of vendors to identify and submit diagnosis codes.⁶ These cases will continue to shape how risk-based reimbursement interacts with FCA liability.

Across these domains, the source of investigations is shifting. While whistleblowers continue to drive a significant number of cases, DOJ and HHS increasingly open investigations based on data-analytics-driven anomaly detection rather than relator allegations.⁷ This shift correlates with increased collaboration across federal and state agencies and between government and commercial payers.⁸

With enforcement moving faster and targeting broader networks, self-disclosure and cooperation are more important than ever. DOJ has repeatedly signaled that voluntary self-disclosure, prompt remediation, and restitution can mitigate penalties in corporate health care fraud cases.⁹ The alternative—waiting for the government or a relator—carries higher financial, regulatory, and reputational exposure.

Finally, compliance programs must reflect modern operational realities. Effective programs are proactive: they use analytics to monitor claims patterns, audit vendor relationships, validate medical necessity, oversee physician compensation, and rapidly investigate concerns. Compliance cannot be a static policy library; it must be a living operational system with real oversight authority.

In 2026, expectations are rising. The organizations best positioned for the year ahead will be those that strengthen internal controls, scrutinize relationships, and foster a culture where compliance and integrity are practical, normalized, and non-negotiable.

Footnotes

1 See, e.g., HHS and DOJ, Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2023 (2024); DOJ, Fraud Statistics—Overview: Oct. 1, 1986–Sept. 30, 2023 (2024).

2 DOJ, Press Release, National Health Care Fraud Takedown Results in 324 Defendants Charged in Connection With Over $14.6 Billion in Alleged Fraud (June 30, 2025), https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-324-defendants-charged-connection-over-146; DOJ, Press Release, National Health Care Fraud Enforcement Action Results in 193 Defendants Charged over $2.75 Billion in False Claims (June 27, 2024), https://www.justice.gov/archives/opa/pr/national-health-care-fraud-enforcement-action-results-193-defendants-charged-and-over-275-0.

3 U.S. Gov't Accountability Off., Medicare: CMS Fraud Prevention System Uses Claims Analysis to Address Fraud (GAO-17-710, Aug. 30, 2017), https://www.gao.gov/products/gao-17-710; HHS, Press Release, HHS and DOJ Launch False Claims Act Working Group (Apr. 25, 2024), https://www.hhs.gov/press-room/hhs-doj-false-claims-act-working-group.html.

4 HHS OIG, Special Fraud Alert: Telemedicine Arrangement That May Present Heightened Risk of Fraud and Abuse (July 20, 2022), https://oig.hhs.gov/documents/root/1045/sfa-telefraud.pdf.

5 See id.; 42 U.S.C. § 1395nn (2021) (Stark Law); 42 C.F.R. §§ 411.350-.389 (2023) (CMS regulations implementing the Stark Law).

6 DOJ, Press Release, Medicare Advantage Provider Independent Health to Pay $98 Million to Settle False Claims Act Suit (Feb. 6, 2024), https://www.justice.gov/archives/opa/pr/medicare-advantage-provider-independent-health-pay-98m-settle-false-claims-act-suit; DOJ, Press Release, Medicare Advantage Provider Seoul Medical Group and Related Parties Pay Over $62 Million to Settle False Claims Act Allegations (Sept. 5, 2023), https://www.justice.gov/opa/pr/medicare-advantage-provider-seoul-medical-group-and-related-parties-pay-over-62m-settle.

7 DOJ, National Health Care Fraud Takedown (2025).

8 See, e.g., HHS OIG., Medicaid Fraud Control Units Annual Report: Fiscal Year 2024 (Mar. 11, 2025) (OEI-09-25-00090).

9 DOJ, Corporate Enforcement and Voluntary Self-Disclosure Policy (Jan. 17, 2023).

Originally published by American Health Law Association's Top Ten: Health Law Forecast 2026

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