This week, the U.S. Department of Justice (DOJ) announced criminal charges involving over $14.6 billion in intended losses that were brought as a result of DOJ’s 2025 National Health Care Fraud Takedown. The charges involved 324 defendants, including 96 doctors, nurse practitioners, pharmacists, and other medical professionals across the country. According to DOJ’s press release, the Takedown is the largest healthcare fraud initiative in its history and has already resulted in the seizure of more than $245 million in cash, luxury cars, and other assets. The Takedown also involved civil cases and settlements, as well as the suspension or revocation of privileges for 205 healthcare providers. The conduct at issue in the Takedown involved a wide range of fraudulent practices including an international scheme to defraud Medicare using stolen identities, as well as schemes involving fraudulent wound care claims, opioid trafficking, telemedicine fraud, kickbacks, and medically unnecessary diagnostic testing.
The Takedown is notable not only for its sweeping scope and effective coordination among multiple federal and state law enforcement agencies, but also for the role advanced data analytics, artificial intelligence and cloud computing played in identifying suspicious patterns and supporting the enforcement effort. For example, one of the schemes included a transnational criminal organization that submitted $10.6 billion in fraudulent heath care claims for medical equipment by using stolen identities and confidential medical information of Medicare beneficiaries. According to DOJ’s press release, the DOJ Criminal Division’s Fraud Section and its partners detected anomalous billing patterns through proactive data analytics, and the government was able to prevent a large portion of the fraudulent claims from being paid. DOJ has previously emphasized the role of data analytics to aid in identifying and combating fraud.
At the same time that the government is enhancing its use of technology to support its enforcement efforts, those seeking to defraud the government are making use of advanced technology as well. In one of the schemes involved in the Takedown, defendants allegedly used artificial intelligence to create fake recordings of Medicare beneficiaries consenting to receive certain products that were then billed to Medicare. As artificial intelligence tools become more ubiquitous, they are likely to play an increasing role in facilitating healthcare fraud.
While technology will undoubtedly continue to transform how healthcare fraud is both committed and detected, humans will remain essential to the effort to detect and prosecute fraud. Whistleblowers with information about how fraud is occurring and the mental state of the people perpetrating it will remain a critical source for effective healthcare fraud enforcement. In fiscal year 2023 alone, over $2.3 of the $2.68 billion DOJ recovered in civil cases arose from lawsuits initiated by whistleblowers. Whistleblowers have been central to efforts to combat healthcare fraud in a wide range of areas, including:
- Medicare Advantage risk-adjustment fraud
- Medical loss ratio fraud
- Off-label marketing by pharmaceutical companies
- Off-label marketing of medical devices and implants
- Upcoding and unbundling
- Kickbacks
- Stark Law
- Lack of medical necessity
- Telemedicine fraud
- Electronic health records (EHR) fraud
- Grant or program fraud
Phillips & Cohen has expertise in all areas of healthcare fraud. If you know of potential healthcare fraud and would like to speak with an experienced whistleblower attorney, contact Phillips & Cohen for a confidential review of your case.