On July 2, 2025, the U.S. Department of Justice (DOJ) Civil Division and the U.S. Department of Health and Human Services (HHS) jointly announced the formation of a False Claims Act (FCA) Working Group. This new initiative underscores a coordinated federal enforcement strategy focused on identifying and addressing fraud in federally funded health care programs, particularly Medicare Advantage and Medicaid managed care. The announcement comes days after Matthew R. Galeotti, Head of DOJ’s Criminal Division, announced the results of the “largest coordinated health care fraud takedown in the history of the Department of Justice”  and the creation of a “Health Care Fraud Data Fusion Center” comprised of data specialists that will “break down information silos, using coordinated data analysis to enable our investigative teams to quickly identify and dismantle emerging fraud schemes.” Taken together, these announcements demonstrate the DOJ’s effort—in both civil and criminal divisions—to strengthen its collaboration with HHS to investigate and prosecute health care fraud.

Overview of the Working Group

The FCA Working Group is composed of leadership from:

  • HHS Offices of General Counsel and Inspector General
  • Centers for Medicare & Medicaid Services Center for Program Integrity, and
  • DOJ Civil Division and designees from the U.S. Attorney’s Offices

The cross-agency collaboration reflects DOJ and HHS’s intent to enhance and maximize investigative capacity through inter-agency referrals and coordinated litigation strategies. The Working Group will also leverage HHS resources through enhanced data mining and assessment of HHS and HHS-OIG report findings. The Working Group’s information sharing means that health plans, providers, and vendors should expect more focused civil and administrative investigations, often running concurrently.

Priority Enforcement Areas

The agencies linked their announcement to the “priority FCA matters” laid out by Assistant Attorney General Brett Shumate in his June 11 memorandum on Civil Division Enforcement Priorities. The FCA Working Group is expected to focus on:

  • Medicare Advantage
  • Drug, device or biologics pricing, including arrangements for discounts, rebates, service fees, and formulary placement and price reporting
  • Barriers to patient access to care, including violations of network adequacy requirements
  • Kickbacks related to drugs, medical devices, durable medical equipment, and other products paid for by federal healthcare programs
  • Materially defective medical devices that impact patient safety
  • Manipulation of Electronic Health Records systems to drive inappropriate utilization of Medicare covered products and services

Notably, HHS leadership emphasized during a July 2 American Health Law Association panel that network adequacy and access violations will be a continued focus. This area has gained traction in both FCA and state enforcement actions. Key risk areas include inaccurate provider directories; misstatements in CMS submissions and marketing materials regarding network access; and failure to meet state or federal appointment wait-time and geographic access standards. False or misleading attestations concerning network sufficiency may result in FCA exposure if they lead to improper reimbursement or induce beneficiary plan selection. 

The FCA Working Group continues to encourage whistleblower reports in high-priority enforcement areas. The FCA Working Group also urges companies to consider voluntary disclosure, cooperation, and remediation in line with § 4-4.112 of the Justice Manual.

Health care entities—including Medicare Advantage plans, Medicaid managed care entities, provider groups, life science companies and delegated vendors—should take proactive steps to strengthen their compliance programs in light of the DOJ and HHS’s coordinated focus on FCA enforcement. This includes building and maintaining robust programs that ensure accurate risk adjustment coding, truthful network adequacy attestation, and effective oversight of delegated entities and downstream vendors. Organizations must monitor DOJ policy updates, HHS enforcement trends, and FCA-related guidance to stay ahead of government scrutiny and effectively address concerns raised in whistleblower actions.

Tags: Department of Health and Human Services, Department of Justice, DOJ, False Claims Act (FCA), FCA, FCA Working Group, HHS, Medicaid, Medicaid Managed Care, Medicare Advantage
Print:
Email this postTweet this postLike this postShare this post on LinkedIn
Photo of Megan Beaver Megan Beaver

Megan F. Beaver is a counsel at Crowell & Moring’s San Francisco office, where she is a member of the firm’s Health Care Group. Megan’s practice focuses on health care regulatory matters, with an emphasis on state licensure and compliance issues. Megan works

…

Megan F. Beaver is a counsel at Crowell & Moring’s San Francisco office, where she is a member of the firm’s Health Care Group. Megan’s practice focuses on health care regulatory matters, with an emphasis on state licensure and compliance issues. Megan works with national and regional health plans (including full service and specialty plans), Medicare Advantage, commercial and Medicaid health plans on a range of regulatory compliance matters, license filings, including plan-to-plan contracts and pharmacy benefit manager contracts, material modifications, and drafting and negotiating provider contracts. In addition, she assists and advises clients on state regulator parity investigations and responding to Department of Managed Health Care (“DMHC”) Office of Enforcement investigations. Megan has also assisted clients to obtain licensure as health care service plans under California’s Knox-Keene Health Care Service Plan Act.

Prior to joining the firm, Megan was Senior Corporate Counsel at Centene Corporation. In this role, Megan analyzed proposed, pending and recently enacted legislation, as well as agency guidance, to determine the impact on health plan operations. She advised plan leadership on how to implement and effectuate the required action. Megan also advised the California plan leadership on how to manage the dual authorities of government programs and plan licensure (i.e. Medicare/Medi-Cal and DMHC).

Read more about Megan Beaver
Show more Show less
Photo of Troy A. Barsky Troy A. Barsky

Troy Barsky is a partner in Crowell & Moring’s Washington, D.C. office, and serves as a member of the firm’s Health Care Group Steering Committee where he focuses on health care fraud and abuse, and Medicare and Medicaid law and policy. Troy counsels…

Troy Barsky is a partner in Crowell & Moring’s Washington, D.C. office, and serves as a member of the firm’s Health Care Group Steering Committee where he focuses on health care fraud and abuse, and Medicare and Medicaid law and policy. Troy counsels all types of health care entities, including hospitals, group practices, and health plans on the physician self-referral law (Stark Law) and the Anti-Kickback Statute, innovative healthcare delivery models, such as Accountable Care Organizations (ACOs), and Medicare & Medicaid payment and coverage policy. He also defends clients seeking resolution of government health care program overpayment issues or fraud and abuse matters through self-disclosures and negotiated settlements with the U.S. Department of Justice, U.S. Health & Human Services Office of the Inspector General and the Centers for Medicare & Medicaid Services (CMS).

Read more about Troy A. Barsky
Show more Show less
Photo of Preston Pugh Preston Pugh

Preston Pugh helps companies, board committees and large organizations conduct internal investigations and respond to government investigations, often stemming from high stakes whistleblower complaints. He is a partner at Crowell & Moring and co-leads its False Claims Act Practice. For more than 20…

Preston Pugh helps companies, board committees and large organizations conduct internal investigations and respond to government investigations, often stemming from high stakes whistleblower complaints. He is a partner at Crowell & Moring and co-leads its False Claims Act Practice. For more than 20 years, he has helped clients navigate many different types of crises—including commercial and government contract fraud investigations; C-suite corporate ethics concerns; whistleblower retaliation claims; broad-based harassment and discrimination complaints; investigations by Congress; and related litigation. He has been recognized by the Legal 500 for his work in investigations.

Read more about Preston Pugh
Show more Show less
Photo of Michael Shaheen Michael Shaheen

Michael Shaheen is a partner in the White Collar & Regulatory Enforcement and Health Care groups in the Washington, D.C. office of Crowell & Moring. His practice focuses on federal litigation, investigations, and enforcement actions. Michael has significant experience with the False Claims…

Michael Shaheen is a partner in the White Collar & Regulatory Enforcement and Health Care groups in the Washington, D.C. office of Crowell & Moring. His practice focuses on federal litigation, investigations, and enforcement actions. Michael has significant experience with the False Claims Act (FCA), with particular emphasis on health care fraud.

Before joining Crowell & Moring, Michael served as a Trial Attorney with the Fraud Section of the Department of Justice (DOJ), where his work primarily involved investigating and prosecuting FCA matters. At DOJ, he obtained judgments totaling hundreds of millions of dollars and was involved in the settlement of numerous false claims cases of similar magnitude. Michael served in a variety of roles in these cases, ranging from first-chair trial attorney to lead investigator.

Read more about Michael Shaheen
Show more Show less
Photo of Payal Nanavati Payal Nanavati

Payal Nanavati is a counsel in the firm’s Washington, D.C. office, where she practices in the Health Care and Government Contracts groups. Payal’s government contracts practice focuses on defending companies under the False Claims Act, litigation before the Armed Services Board of Contract…

Payal Nanavati is a counsel in the firm’s Washington, D.C. office, where she practices in the Health Care and Government Contracts groups. Payal’s government contracts practice focuses on defending companies under the False Claims Act, litigation before the Armed Services Board of Contract Appeals, and bid protests before the Government Accountability Office. Her health care practice includes working with providers and plans seeking to comply with laws and regulations applicable to digital health initiatives, fraud and abuse, and mental health parity.

Payal is a co-host of Crowell & Moring’s health care podcast, Payers, Providers, and Patients – Oh My!, which covers legal and regulatory issues that affect health care entities’ in-house counsel, executives, and investors.

Payal’s recent pro bono representations include clients seeking asylum or legal immigration status under the Violence Against Women Act and successfully defending against eviction attempts by a client’s landlord. During law school, Payal served as a staff member for the Journal of Gender and Law.

Read more about Payal Nanavati
Show more Show less
Photo of Alexander J. Kramer Alexander J. Kramer

Alexander J. Kramer is a partner in the White Collar and Regulatory Enforcement Group, bringing a wealth of experience from his distinguished career at the United States Department of Justice (DOJ). Alex has extensive experience in white collar crime and investigations, including the…

Alexander J. Kramer is a partner in the White Collar and Regulatory Enforcement Group, bringing a wealth of experience from his distinguished career at the United States Department of Justice (DOJ). Alex has extensive experience in white collar crime and investigations, including the Foreign Corrupt Practices Act (FCPA) and anti-corruption issues, health care fraud, significant fraud by government contractors, public companies, financial institutions, and other entities dealing with the DOJ, the U.S. Securities and Exchange Commission (SEC), the Commodity Futures Trading Commission (CFTC), and related parallel enforcement actions.

Read more about Alexander J. Kramer
Show more Show less
Photo of Kelly Hightower Hibbert Kelly Hightower Hibbert

Kelly Hightower Hibbert is a counsel in Crowell & Moring’s Washington, D.C. office, where she is a member of the firm’s Health Care Group. Kelly focuses her practice on complex commercial litigation before federal and state courts, administrative agencies, and arbitral forums. She…

Kelly Hightower Hibbert is a counsel in Crowell & Moring’s Washington, D.C. office, where she is a member of the firm’s Health Care Group. Kelly focuses her practice on complex commercial litigation before federal and state courts, administrative agencies, and arbitral forums. She is also experienced in defending government investigations involving False Claims Act allegations. In addition to her work as defense counsel, Kelly represents health care clients pursuing recovery of monies lost as a result of fraud, waste, and abuse.

Read more about Kelly Hightower Hibbert
Show more Show less
Related Posts
Seventh Circuit Clarifies Limits on Advertising Payments under the AKS
April 29, 2025
First Circuit Clarifies “Resulting From” standard under Anti-Kickback Statute, Reshaping False Claims Act Litigation
February 21, 2025
Stringent Requirements for Pleading Fraud Under Rule 9(b).
November 5, 2024