The Department of Justice’s New Fraud Division Health Care Enforcement Priorities

The Department of Justice Elevates Health Care Fraud as a Core National Enforcement Priority

On August 13, 2026, the National Fraud Enforcement Division (the Fraud Division) issued a memorandum, The Fraud Division’s Enforcement Priorities, outlining the Department of Justice’s (DOJ’s) strategic framework for combating fraud across the U.S. The memorandum establishes five primary enforcement priorities: public trust and financial integrity, health care, internal revenue, global trade and commerce, and corporate misconduct.

Although health care fraud has long been a focus of federal enforcement efforts, the memorandum confirms that it remains a central priority for the DOJ. The creation of a dedicated Health Care Fraud Section within the recently formed Fraud Division and the expansion of health care fraud enforcement resources suggests that the government intends to continue devoting significant attention to this area.

The memorandum reflects a broader government strategy focused on deploying enhanced data analytics, financial forensics, nationwide coordination and key prosecutorial resources to identify and pursue complex fraud schemes. For health care providers, payors, investors, private equity sponsors and their advisors, health care fraud enforcement will remain one of the DOJ’s most significant priorities, with increasing emphasis on data-driven investigations and coordinated scrutiny of both operational and financial misconduct.

Why Health Care Continues to Be a Prime Enforcement Focus

According to the memorandum, national health care expenditures are expected to grow from more than $3 trillion annually to more than $7 trillion, with estimates that 3%-10% of health care spending may be lost to fraud. The DOJ specifically identifies fraud as a significant contributor to rising health care costs and a threat to patient care, particularly for vulnerable populations such as the elderly, disabled and chronically ill.

Recognizing the scale of these risks, the DOJ has established a Health Care Fraud Section within the new Fraud Division and announced plans to expand the historically successful Health Care Fraud Strike Force model through additional personnel, data analytics capabilities and advanced technology resources.

Health care organizations should expect increased investigative activity and a heightened focus on large-scale schemes involving billing practices, referrals, prescribing activity, reimbursement models and financial relationships.

Key Health Care Risks Identified by the DOJ

The memorandum identifies several areas that will receive heightened attention from federal prosecutors.

Telemedicine, Medicare and Medicaid fraud

The DOJ specifically highlights telemedicine programs and fraud involving Medicare and Medicaid as enforcement priorities. As health care delivery continues to evolve through digital platforms and remote care models, regulators are increasingly using data analytics to identify unusual utilization patterns, billing anomalies and reimbursement trends that may indicate improper conduct.

Organizations should anticipate greater scrutiny of:

• Medical necessity documentation
• Provider enrollment and credentialing
• Billing practices
• Revenue cycle management controls
• Relationships among providers, vendors and referral sources

Home health and hospice enforcement

The memorandum expressly identifies home health and hospice schemes as a priority, noting concerns regarding exploitation of vulnerable elderly populations. Home health and hospice providers have historically attracted significant regulatory attention due to risks associated with patient eligibility determinations, service documentation and reimbursement structures.

Areas likely to receive increased attention include:

• Eligibility assessments
• Hospice admissions
• Visit documentation
• Staffing and service delivery records
• Claims submitted for services not rendered

Controlled substance diversion and opioid enforcement

The DOJ continues to emphasize controlled substance diversion, illegal prescribing and dispensing practices. The memorandum notes that improper prescribing contributes to addiction and harms communities nationwide.

Health care organizations should continue evaluating:

• Prescribing patterns
• Pharmacy dispensing activity
• Controlled substance inventory controls
• Monitoring and auditing programs
• Compliance with federal and state-controlled substance regulations

Marketing of unsafe products and services

The memorandum also targets companies and individuals that “deceptively market unsafe products and services.” This reflects an increasing focus on representations made to patients, regulators, government health care programs and commercial payors.

Potential risk areas include:

• Claims regarding the safety, efficacy or clinical benefits of products and services
• Representations regarding reimbursement eligibility and insurance coverage
• Advertising and promotional practices for medical devices and pharmaceuticals
• Representations regarding FDA approval, clearance, labeling or regulatory compliance
• Marketing practices involving third-party sales representatives, agents or referral partners

Financial crimes associated with health care fraud

Importantly, the DOJ makes clear that health care investigations will not be limited to underlying billing or regulatory violations. Prosecutors will also focus on associated financial crimes, including complex money laundering, tax violations and related financial misconduct.

Organizations should expect investigators to follow financial transactions beyond the health care claims themselves, examining ownership structures, related-party transactions, fund flows, tax reporting and financial reporting practices.

The Growing Role of Financial Forensics in Health Care Fraud Matters

The memorandum highlights the DOJ’s increasing reliance on data analytics, technology-enabled investigations and large-scale analysis of operational and financial data to identify potential fraud schemes. As enforcement becomes more data-driven, forensic accountants and health care consultants are likely to play an expanding role in identifying potential fraud indicators, analyzing financial and operational data, tracing transactions, evaluating ownership and business relationships, identifying anomalous patterns and trends, supporting investigations, assessing compliance risks and helping organizations respond to regulatory inquiries and enforcement actions.

What This Means for Health Care Organizations

Perhaps the most significant takeaway from the memorandum is how the Fraud Division intends to pursue these cases. The DOJ has made clear that data analytics, financial forensics and technology-enabled investigations will play a central role in identifying and prosecuting health care fraud. Through investments in advanced analytics, data science resources and a dedicated National Fraud Detection Center, the government is positioning itself to proactively identify potential fraud schemes by analyzing large volumes of billing, operational and financial data.

As a result, health care organizations should assume that regulators have increasingly sophisticated tools to identify anomalies, outliers and patterns that may warrant further scrutiny. Rather than relying solely on traditional audits, whistleblower complaints or referrals, enforcement agencies are increasingly using data to detect potential misconduct before it is otherwise reported.

Health care providers, investors, compliance officers and counsel should consider adopting a similarly proactive approach by regularly evaluating:

• Billing and reimbursement outliers
• Referral patterns and physician relationships
• Telemedicine utilization trends
• Home health and hospice eligibility metrics
• Controlled substance prescribing and dispensing patterns
• Revenue cycle anomalies
• Related-party transactions and ownership structures
• Potential Anti-Kickback Statute and Stark Law risk indicators

Organizations that regularly evaluate their financial and operational data for potential risk factors are often better positioned to identify emerging risks, remediate issues before they escalate and respond effectively to regulatory inquiries.

Looking Ahead

The DOJ’s new enforcement framework underscores that health care will remain one of the federal government’s most significant anti-fraud priorities. Beyond establishing a dedicated Health Care Fraud Section within the new Fraud Division, the memorandum signals a broader shift toward data-driven enforcement, leveraging advanced analytics, financial forensics and cross-agency collaboration to identify and pursue complex health care fraud schemes.

For health care organizations, compliance programs must evolve alongside the government’s enforcement capabilities. Traditional monitoring activities remain important, but organizations should incorporate data analytics, forensic reviews and proactive risk assessments into their compliance and governance frameworks. The same analytical techniques being deployed by regulators can be powerful tools for identifying vulnerabilities, evaluating transactions and billing activity, investigating potential misconduct and strengthening internal controls.

As enforcement priorities continue to evolve, health care entities that combine operational expertise with data analytics, forensic accounting and investigative capabilities will have tools to anticipate risks, respond to regulatory scrutiny and protect organizational value. In an environment where regulators are increasingly using data to detect fraud, organizations should be asking not only whether they are compliant, but whether their own data would support that conclusion.

Weaver Can Help Health Care Organizations Evaluate Fraud Risk

Organizations facing greater scrutiny can benefit from a proactive review of the financial and operational data underlying their health care activities. Weaver’s forensic accounting and litigation support team can help evaluate fraud risks, strengthen compliance efforts and prepare for an growing data-driven enforcement environment. Contact us today.

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