DOJ Criminal Fraud Section 2025 Year in Review – Health Care Fraud Is Front and Center

On January 22, 2026, the Department of Justice (DOJ or the Department) Criminal Fraud Section issued its 2025 Year in Review summary (YIR Summary). Our more detailed analysis of the full YIR Summary can be found here. DOJ’s Health Care Fraud Unit (the HCF Unit) is focused on “prosecuting complex health care fraud matters and cases involving the illegal prescription, distribution, and diversion of controlled substances.” To carry out its mission, in 2025, the HCF Unit operated 8 Health Care Fraud Strike Forces in 26 federal judicial districts across the nation. The HCF Unit’s reported average return on investment is $106.76 per $1 spent. 

Health Care Enforcement Priorities Identified

The “centerpiece” of the HCF Unit’s 2025 efforts was the annual Health Care Fraud Takedown (Takedown), which targeted hundreds of defendants and involved billions of dollars in intended losses. Our more detailed analysis of the Takedown can be found here. The Takedown reflected “several key priorities in health care fraud enforcement,” and we highlight some below.  

The Wound Care Initiative: According to the YIR Summary, Medicare payments for amniotic wound allografts, also known as skin substitutes, have “exploded” in recent years, “driven by illegal kickbacks from wholesalers and medically unnecessary applications by providers incentivized by the high reimbursement rates.” To normalize usage of skin substitutes, the Centers for Medicare & Medicaid Services (CMS) changed its reimbursement methodology as of January 1, 2026, and now reimburses most skin substitutes at lower rates. The change is expected to reduce Medicare spending on skin substitutes by nearly 90%. While lower reimbursement rates are likely to result in less fraud and abuse in this space going forward, wholesalers and providers should review past practices and consider whether self-disclosure is necessary. 

The Telemedicine Initiative: Over the past few years DOJ has pursued a variety of fraud schemes involving telemedicine, such as those discussed here. Given that the expansion of digital health services presents both innovation opportunities and “grave fraud risks,” it comes as no surprise that the HCF Unit has “intensified” its focus on telemedicine-related schemes. In particular, DOJ is prioritizing cases “in which telemedicine platforms were exploited to generate false claims, improperly prescribe controlled substances, or bypass necessary clinical oversight, threatening patient safety and defrauding federal health care programs.” 

The Substance Abuse Treatment Initiative: Additional enforcement efforts were devoted in 2025 to the exploitation of individuals seeking substance abuse treatment. For example, prosecutions uncovering “treatment centers billing federal and state health care programs for nonexistent or misrepresented services, using illegal kickbacks to recruit patients, and diverting public funds intended to support genuine recovery” were highlighted in the YIR Summary. 

The Prescription Drug Abuse Initiative: Consistent with its focus on substance abuse and the addiction crisis, DOJ prioritized addressing the dangers of unsafe prescribing tactics and the diversion of controlled substances disguised as legitimate medical care (e.g., cases involving pill mills). 

Traditional Health Care Fraud Schemes: Despite the existence of the above-listed focus areas, DOJ unsurprisingly remains committed to prosecuting traditional health care fraud schemes, even if they do not squarely fall into one of the specific initiatives named. 

Foreign Actors: Consistent with the America First directives of the administration, DOJ is focused on fraud schemes perpetrated by foreign actors that exploit U.S. health care programs, which is a newly articulated health care enforcement priority. For example, the Takedown included the arrest of foreign actors who generated audio recordings using artificial intelligence that purported to reflect Medicare beneficiaries’ consent to receive products. The defendants sold these recordings, along with stolen Medicare beneficiary data, to labs and durable medical equipment companies, which, in turn, relied upon the recordings to support allegedly false claims to Medicare. 

Corporate Resolutions Announced

DOJ highlighted two 2025 corporate resolutions in the YIR Summary involving Troy Health and Kimberly-Clark, and those cases resulted in, respectively, a Non-Prosecution Agreement (NPA)[1] and a Deferred Prosecution Agreement (DPA).[2] Our more detailed analysis of the streamlined resolutions in the Troy Health and Kimberly-Clark cases can be found here. While neither resolution originated with a voluntary self-disclosure (VSD) – on which DOJ has placed a premium in recent years – DOJ utilized its discretion to offer streamlined resolutions with relatively favorable outcomes. 

These cases underscore that, even if a company is not able to reap the benefits associated with VSD (which can result in a declination), other swift resolutions such as NPAs and DPAs appear more readily available than ever for corporate actors that demonstrate a commitment to cooperation and remediation. 

Evolving Technologies and Methods Used to Detect Fraud 

According to the YIR Summary, the HCF Unit’s strategic use of data analytics has paid dividends. In 2025, the HCF Unit’s Data Analytics Team completed 2,085 data requests and 164 proactive data referrals that aided charging decisions, resolution of significant matters, and seizures. 

For example, in one case study, the Data Analytics Team identified billing anomalies associated with a facility in California that billed Medicare for Botox injections to treat chronic migraines. The data demonstrated that other providers had not billed the same beneficiaries for such injections. There were also injections allegedly administered at times when the facility was closed. This data-driven investigation culminated in an October 2025 indictment of the facility’s owner for billing injections that were medically unnecessary and/or never provided. 

The HCF Unit is also working closely with agency partners to create a Health Care Fraud Data Fusion Center that will leverage cloud computing, artificial intelligence, and advanced analytics to identify health care fraud schemes. DOJ believes this effort will bolster detection efforts, efficiency, and rapid prosecutions. As mentioned above with respect to the potential availability of streamlined corporate resolutions, the Department appears highly focused on maximizing efficiency, and it is investing in methods to realize this goal. 

New England Strike Force Expansion

In September 2025, the HCF expanded its New England Strike Force into the District of Massachusetts. This development was not particularly surprising as the District of Massachusetts has already long served as a hub for significant health care cases. 

DOJ recognized the importance of adequately resourcing its investigatory function in “critical” locations for “health care innovation, life sciences, and medical research” while noting that the Boston area serves as home to leading medical institutions and biotech companies. 

Takeaways

Health care enforcement is a top priority, and likely the top priority, for DOJ – both through the emphasis on specific initiatives that further the current administration’s goals and more traditional health care fraud cases. 

All of the enforcement priorities outlined in the YIR Summary are expected to remain focus areas for years to come. Evaluating both the geographic and substantive areas of priority for DOJ is critical for health care companies. Those that fall within priority areas should assess and bolster their compliance systems accordingly.

For corporate actors, streamlined resolutions – such as NPAs and DPAs – are more readily available. Self-disclosure, cooperation, remediation, and appeals to principles of efficiency can all prove useful tools for the savvy corporate actor. 

Subscribe To Viewpoints