Patrick Queen Anne
Federal law enforcement agencies on criminal violations of medical fraud, waste and abuse are likely to increase this year.
Despite numerous reports that the Department of Justice (DOJ) is facing cost-cutting measures and forcing a drain from government efficiency (DOGE), it is likely that the ranks of agents and prosecutors handling medical issues are increasing despite the DOJ shifting the priorities of white-collar criminal execution.
This means search warrants, subpoena, target letters, prosecutions and law enforcement actions from the FBI, Hhsoig, DEA and other federal agencies.
The DOJ under the Trump administration has been speaking out when it announced how to prioritize criminal cases, including immigration, violent crime and cartel-related drug trafficking. As a result, DOJ is shifting resources from criminal cases, including public corruption to other sectors, foreign corruption practices, and “creptocracy” initiatives.
Given the administration's focus on detering fraud, waste and abuse, the DOJ will refocus its resources to investigate and claim medical fraud in federal programs. In fact, the Medicare and Medicaid programs (and other federal health benefits programs) pay more than $1 trillion in claims per year. And federal criminal prosecutions and investigations related to program fraud, waste, and abuse will return money to the public FISC. More prosecutions and investigations have led to more money being returned to the government.
Scott Armstrong
The FBI, HHS-OIG, DEA and other law enforcement agencies partner with prosecutors in the Fraud Section Healthcare Fraud Units and the offices of U.S. lawyers nationwide to investigate and claim criminals related to medical fraud, wire fraud, anti-kickback violations, illegal prescriptions and other health services.
In recent years, federal law enforcement agencies have targeted the owners and operators of call centers that contact Medicare and Medicaid beneficiaries, laboratories that perform genetic testing, durable medical device companies, calm homes, remote health companies, addiction treatment facilities, behavioral health providers, and licensed practitioners, many of whom were illuminated by online or telehealth settings.
More recently, federal agencies have also launched criminal investigations regarding the distribution/prescription of ketamines and amphetamines, fraud schemes including enrollment in insurance plans, and filing claims for DMEs, genetic testing, prescription drugs, and other medical services or products.
As a result, federal prosecutors investigated and filed the owners of for-profit healthcare companies, investors, claimants, patient brokers, providers and other healthcare professionals. These cases often include charges under federal conspiracy law. This leads to extensive national research that affects all aspects of the industry, and can involve businesses and individuals far from actual criminal activity.
These investigations also collect evidence using email, mobile phones, assumption search warrants, corporate and financial records subpoena, and other methods of invading the operations of innocent third-party entities.
The healthcare industry should look forward to a drastic initiative in 2025 in law enforcement initiatives to combat healthcare fraud. Additionally, health professionals should expect to see more investigations and investigations from private insurance to combat the same. Navigate and handle the scope of these inquiries requires skill and experience.
It's already a challenging time for healthcare providers and professionals, as insurance payers increase audit activity, reimbursement rates stagnate, thin margins, and fewer people work in healthcare. If you or your entity finds themselves during enforcement action or investigation, there are ways to mitigate risk and avoid wasting valuable time and resources.
Patrick J. Queenn and Scott Armstrong are former federal prosecutors in the US Department of Justice, the fraud division and the healthcare fraud division. Queen Anne is based in Sheehan Finney, working with clients in the Boston area and New Hampshire. Armstrong is at McGovern Weems PLLC in Washington, DC. It advocates healthcare providers, businesses, and individuals involved in federal criminal investigations and prosecution in federal districts around the country.
