Record-breaking Year for the False Claims Act – Health Care Enforcement Trends

Key Takeaways

• Settlements and judgments under the False Claims Act (FCA) exceeded $6.8 billion in fiscal year 2025
  • More than double fiscal year 2024
  • Highest amount in the history of the FCA
• Whistleblowers filed 1,297 qui tam lawsuits
  • Again, the highest number in a single year
  • Settlements and judgments exceeding $5.3 billion
  • For the first time, more funds recovered in FCA cases where DOJ declined to intervene ($2.27 billion) than in cases DOJ joined ($2.23 billion)
• Health care fraud remained the leading source of FCA settlements and judgments

Record Year

On January 16, 2026, the Department of Justice (DOJ) announced that FCA settlements and judgments exceeded $6.8 billion in fiscal year 2025. This watershed year for the FCA demonstrates DOJ's intent to be default aggressive and expand enforcement priorities, particularly around health care. "Stopping rampant fraud is a top priority, and this record-breaking year proves the False Claims Act remains one of the government's most powerful weapons against fraud," said Deputy Attorney General Todd Blanche. "We will continue to aggressively deploy it to protect taxpayer dollars and hold all fraudsters accountable."

Enforcement Trends

Health Care Fraud

Of the more than $6.8 billion in FCA settlements and judgments, over $5.7 billion involved the health care industry. The examples listed below show DOJ's commitment to eradicating fraud at every level - insurers, pharmacies, and doctors who seek financial gain over clinical care.

Managed Care

Managed care fraud remained a significant area of concentration, particularly the Medicare Advantage (or Medicare Part C) program, now the largest component of Medicare.

• Independent Health Association and its affiliate agreed to pay up to $98 million to resolve allegations of unsupported and invalid diagnosis codes submitted for Medicare Advantage Plan enrollees to increase payments received from Medicare.
• DOJ intervened in a qui tam against national insurers Aetna Inc., Elevance Health Inc., and Humana Inc., as well as three insurance brokers. DOJ alleged that the insurers agreed to pay hundreds of millions of dollars in kickbacks to the brokers in exchange for steering Medicare beneficiaries to enroll in the insurers' Medicare Advantage plans, regardless of the suitability of those plans for the beneficiaries.

Prescription Drugs

In addition to kickbacks in the managed care setting, DOJ also pursued illegal kickbacks and other misconduct related to drug pricing and dispensing.

• QOL Medical LLC and its co-owner and CEO, Frederick Cooper, agreed to pay $47 million to resolve allegations that they offered kickbacks in the form of free breath testing services to induce claims for QOL's drug Sucraid.
• DOJ pursued several pharmacies for filling opioid prescriptions for controlled substances that lacked a legitimate medical purpose, were not valid and/or were not issued in the usual course of professional practice. DOJ filed a complaint against CVS and resolved a complaint against Walgreens, in which Walgreens agreed to pay up to $350 million.

Unnecessary Services and Substandard Care

Like DOJ's pursuit of pharmacies prescribing opioids, DOJ investigated and resolved matters in which providers billed federal health care programs for medically unnecessary services and substandard care.

• DOJ filed a complaint against Vohra Wound Physicians Management LLC and its founder, Dr. Ameet Vohra, for allegedly causing the submission of false claims to Medicare for overbilled and unnecessary wound care services. Vohra subsequently settled the matter for $45 million.
• American Health Foundation and three affiliated nursing homes agreed to pay $3.61 million to resolve allegations relating to billing Medicare and Medicaid for grossly substandard skilled nursing services.

Procurement, Loan and Grant Fraud

Beyond health care, DOJ targeted fraud in military procurements, violations of critical cybersecurity requirements in federal contracts and grants, and misuse of pandemic relief program funds. But even in many of those areas, the health care industry came into play.

• Health Net Federal Services, Inc. agreed to pay $11.2 million to resolve allegations that it falsely certified compliance with cybersecurity requirements in a contract to administer health benefits for servicemembers and their families.
• Dr. Samad Khan entered into $3.5 million settlement to resolve allegations that he billed for medical evaluations that were not performed at COVID-19 testing sites.
• Covid Test DMV LLC entered into $8.2 million settlement to resolve allegations that it billed the government for COVID-19 tests that were not provided to Medicare beneficiaries.

Looking Ahead

• Clear indication that DOJ will continue to use the FCA to aggressively target fraud in the health care industry through 2026, particularly considering the creation of the Division for National Fraud Enforcement.
• Within health care fraud enforcement, providers should focus on managed care, kickbacks and remuneration, and hybrid FCA theories, and consider other administration priorities that affect the health care industry, like DEI programs and gender-affirming care.
• Note the success of whistleblowers, even without government intervention.
• Continued importance of cooperative measures and compliance, particularly with the surge in whistleblower activity; organizations must be proactive about both compliance and reporting.
• Keep in mind the trend of state attorneys general enforcing their FCA analogues independent of DOJ, particularly where federal and state enforcement priorities diverge.

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