The Numbers Are In – DOH and OIG Report Record Wins

On Jan 16, 2026, the DOJ released its annual report on False Claims Act (FCA) Settlements and Judgments for FY 2025 (the fiscal year ending September 2025). Perhaps not surprisingly, health care fraud remained the leading source of FCAt settlements and judgments representing over $5.7 billion of the total $6.8 billion – or over 85% –  in the past fiscal year. The $6.8 billion figure is the highest annual amount the DOJ has ever reported, with $6.1 billion being reported in 2014 and $2.9 being reported in FY2024. The report also contains the following important statistics:

• 1,297 qui tam suits were filed, representing the highest number of such cases filed in any year. This number is up from the 980 cases filled in FY2024.
• $2.5 billion of the qui tam recoveries – or about 43% – were from cases in which the government chose not to intervene (The DOJ did not join the case), up from 12% in FY2024.
• Even though the number of qui tam cases increased in FY2025, the relators’ share of the awards actually decreased significantly.
• The government opened 401 investigations, which continues the DOJ’s upward trend of opening its own cases (i.e., no qui tam relators were involved).
• Since 1986, when the FCA was strengthened largely due to the efforts of Senator Chuck Grassley, over $85 billion has been recovered.

The DOJ report also highlights three areas of continued DOJ focus:

(1) Medicare Advantage and Managed Care, which deals with allegations of false or unsupported diagnosis codes that result in increased payments for MA enrollees, and allegations of kickbacks being paid by insurance companies to steer beneficiaries to their MA plans.

(2) Prescription Drugs, which deals with allegations of misconduct relating to drug pricing, drug dispensing and kickbacks, including sham speaker programs and inappropriate copay assistance.

(3) Medically Unnecessary Care, which deals with allegations that certain wound care companies are providing and billing for medically unnecessary wound care services, and nursing facilities billing for grossly substandard or non-existent care (so-called “worthless services”).

The following week on January 21, 2026, the OIG released its Semiannual Report to Congress for the time period of April 1, 2025 – September 30, 2025. According to this report, the OIG added $2.43 billion to its monetary impact, which included $2.2 billion in investigative receivables, $82.2 million in audit and evaluation receivables, and $147.4 million in potential cost savings. The report included a discussion of the largest health care fraud Take-Down in DOJ and OIG history, pursuant to which 324 individuals were criminally charged, including 96 licensed medical professionals, for allegedly submitting $14.6 billion of fraudulent claims. This take-down involved DME, telemedicine, diagnostic testing, wound care and drug diversion.

The report also noted that the OIG used advanced data analytics to detect “alarming trends” that warranted follow-up from either HHS or investigators. The OIG provided two examples: skin substitutes, where OIG found that Medicare Part B expenditures for wound care products “skyrocketed” and surpassed $10 billion annually at the end of 2024, and remote patient monitoring, the use of which increased by 31% from 2023 to 2024.

Finally, the following day, on January 22, 2026, the Criminal Division’s Fraud Section released its 2025 Year in Review (Review). With respect to the Health Care Fraud (HCF) Unit, which operated 8 Health Care Fraud Strike Forces in 26 federal judicial districts across the U.S., the Review noted that the Unit uses advanced data analytics and algorithmic methods to identify new health care fraud schemes. In addition to participating in the Take-Down noted above, the Unit secured two corporate resolutions, which held companies accountable for defrauding patients and regulators, and indicted two companies for distributing controlled substances.

In addition, the Unit announced two initiatives: the expansion of the New England Strike Force, which was announced in September 2025, and the creation of a “Health Care Fraud Data Fusion Center,” which was announced as part of the Take-Down, to “improve data sharing, leverage advanced analytics, and detect emerging fraud schemes.” Interestingly, the Review noted that the HCF Unit engaged a third-party consulting group to analyze the return on investment (ROI) using alleged loss values from cases that were “ongoing” at the time of the indictment. The analysis revealed that the average ROI (FY2021-FY2024) by year 10 is $106.76 per $1 spent, with over $4.5 billion in projected savings.

With these sobering statistics in mind, there are a number of things providers and compliance officers should consider doing:

1. Understand that enforcement activity in health care continues to rise, resulting from increases in both government-initiated and qui tam cases.
2. Review (either internally or using a third party) your compliance program to test its effectiveness and quickly address issues where improvement is necessary or advisable.
3. Refresh compliance program awareness with perhaps a new compliance campaign featuring new signage and the creation of incentives to foster a culture of compliance (as noted by the DOJ in its Evaluation of Corporate Compliance Programs last updated in Sept 2024)
4. Utilize the reports to help inform the issues you should consider including on your compliance workplan that may be ripe for compliance audits, such as speaker programs, patient co-pay assistance programs or MSO arrangements.
5. In light of the government focus on medical necessity and quality of care, consider integrating individuals with expertise in quality improvement and clinical care in your compliance committee or compliance team.
6. Focus on implementing or increasing the use of data analytics and algorithms into your compliance program to help early detection of potential issues –  as the reports clearly show, the government is doing it, so should we.
7. Utilize the reports to help support your compliance team’s “ROI” to your leaders and Board. If it isn’t clear already, the reports help demonstrate the high cost of government enforcement.