Last summer, I wrote about the Department of Justice (DOJ) and Department of Health and Human Services (HHS) launching a joint False Claims Act Working Group focused on Medicare fraud enforcement. At the time, the government identified several priority enforcement areas, including Medicare Advantage risk adjustment, kickbacks, drug and device arrangements, and the use of data analytics to identify potentially improper billing.
Earlier this year, we saw one significant example of that enforcement strategy when Aetna agreed to pay $117.7 million to resolve False Claims Act allegations involving inaccurate diagnosis codes submitted through the Medicare Advantage program.
Since then, the enforcement activity has accelerated.
Over the past several months, CMS and DOJ have announced a series of enforcement actions involving billions of dollars in suspected or allegedly improper Medicare claims. Although the cases involve different types of providers and different alleged conduct, several themes are beginning to emerge.
For healthcare providers, the message is increasingly clear: federal enforcement is becoming more data-driven, more proactive, and increasingly focused on identifying suspicious billing patterns before the money is paid.
Medicare Advantage Remains a Major Enforcement Target
The Aetna settlement was not an isolated Medicare Advantage case.
In June, Matrix Medical Network, HealthFair, and HealthFair’s founder agreed to pay a combined $56.5 million to resolve False Claims Act allegations involving diagnoses generated through in-home health assessments of Medicare Advantage beneficiaries.
The government alleged that diagnoses identified during those assessments were submitted for risk-adjustment purposes even though certain diagnoses were not supported by the beneficiaries’ medical records or did not result from sufficiently comprehensive examinations.
Then, in August, Complete Health Partners Holdings agreed to pay $14.1 million to resolve allegations that it caused false diagnosis codes to be submitted through the Medicare Advantage program. That same month, Monogram Health agreed to pay $2.4 million to resolve similar allegations involving diagnosis codes used to increase Medicare Advantage payments.
The largest development came later in August, when The Villages Health System agreed to a $541.5 million settlement after self-disclosing conduct involving allegedly unsupported diagnosis codes used for Medicare Advantage risk adjustment.
Take together with the Aetna settlement, these cases demonstrate that Medicare Advantage risk adjustment remains one of the government’s most active healthcare enforcement areas.
Why it matters: Providers participating in Medicare Advantage arrangements should not view diagnosis coding as merely an administrative function. Diagnoses that affect risk-adjusted payments must be supported by the medical record, and organizations should have processes for identifying and correcting unsupported diagnoses.
CMS Is Increasingly Trying to Stop Payments Before They Happen
Some of the most significant recent developments have not involved False Claims Act settlements at all.
In August, CMS announced that its enforcement efforts had prevented more than $1.6 billion in potentially improper Medicare laboratory payments. According to CMS, those efforts included revoking the Medicare enrollment of 157 laboratory providers, resulting in approximately $732 million in savings.
CMS described several examples in which its systems identified unusual billing shortly after a laboratory began submitting claims. In one instance, CMS identified a laboratory suspected of billing for services that were never performed, denied approximately $1.2 million in claims, continued monitoring the laboratory after its billing practices changed, and ultimately suspended additional payments and revoked the provider.
CMS also reported that, since January 1, 2026, its Fraud Defense Operations Center had suspended more than $371 million in Medicare payments involving 267 providers and suppliers. Those suspensions included more than $226 million associated with suspected durable medical equipment billing, more than $53 million involving skin substitutes, and more than $23 million involving hospice providers.
Why it matters: Historically, providers may have thought about fraud enforcement primarily in terms of audits, investigations, or False Claims Act litigation occurring months or years after claims were submitted. CMS is increasingly emphasizing real-time and prepayment intervention. Sudden changes in billing volume, unusual utilization patterns, newly enrolled entities, and other statistical anomalies can trigger scrutiny before claims are paid.
Durable Medical Equipment Is Under Particularly Heavy Scrutiny
In September, CMS announced that it had identified 11 durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) companies associated with more than $3.4 billion in suspected fraudulent billing during 2025 and 2026.
According to CMS, the companies had no claims history before 2025 and subsequently submitted enormous volumes of claims. CMS identified billing involving beneficiaries who were deceased as well as beneficiaries who allegedly never requested or received the equipment being billed.
CMS moved to bar the companies from receiving future Medicare Advantage Part C and Part D payments.
This action follows CMS’s broader focus on DMEPOS as a high-risk area for program integrity enforcement.
Why it matters: Extreme billing patterns are increasingly easy for CMS to identify. Providers and suppliers should assume that CMS is comparing their claims activity against historical billing, peer organizations, beneficiary information, utilization patterns, and other available data.
Medical Necessity and Kickbacks Remain A Focus
New technology may be changing how the government identifies potential fraud, but many of the underlying compliance problems remain familiar.
In July, Access DX Laboratory, its former CEO, and a Florida businessman agreed to pay a combined $36.4 million to resolve False Claims Act allegations involving genetic testing.
The government alleged that the defendants paid kickbacks to marketers for patient referrals, paid telemedicine providers for fraudulent physician orders, unbundled genetic-testing billing codes, and billed Medicare and Medicaid for medically unnecessary testing.
Similarly, earlier this year, Traditions Health agreed to pay $34 million after self-disclosing allegations involving medically unnecessary home health services and financial benefits provided to physician medical directors who referred Medicare beneficiaries to the company.
And in May, Takeda Pharmaceuticals agreed to pay approximately $13.7 million to resolve allegations that it provided improper payments to healthcare providers to induce prescriptions of an antidepressant medication reimbursed by federal healthcare programs.
Why it matters: The Anti-Kickback Statute and medical-necessity requirements remain central enforcement tools. Providers should pay particular attention to relationships involving referral sources, medical director arrangements, marketers, telemedicine providers, laboratories, and other third parties whose compensation or activities may influence federally reimbursed services.
CMS Is Also Using Enrollment as an Enforcement Tool
CMS’s enforcement strategy is extending beyond individual claims.
In May, CMS imposed a nationwide six-month moratorium on new Medicare enrollment for home health agencies and hospice providers. The moratorium also applies to certain changes in majority ownership.
CMS characterized home health and hospice as high-risk provider categories and explained that the moratorium was intended to prevent potentially fraudulent providers from entering Medicare while the agency continues its program-integrity efforts.
The agency has also expanded enhanced oversight and prepayment review initiatives targeting hospice providers.
Why it matters: Medicare enrollment itself is increasingly part of CMS’s fraud-prevention strategy. Providers operating in sectors CMS considers high risk should expect greater scrutiny not only of claims, but also of enrollment applications, ownership changes, certifications, and continued participation in Medicare.
The Scale of Enforcement Is Growing
These individual actions are part of a much larger enforcement effort.
In June, DOJ announced its 2026 National Health Care Fraud Takedown, resulting in charges against 455 defendants, including 90 physicians and other licensed medical professionals, in connection with more than $6.5 billion in alleged fraudulent claims.
The cases involved a wide range of alleged schemes, including durable medical equipment, skin substitutes and wound care products, laboratory testing, hospice services, and other medically unnecessary or unprovided services.
Meanwhile, CMS reports that its Medicare program-integrity efforts produced $41.9 billion in savings during fiscal year 2025, a 59% increase from the prior year.
Those numbers help explain why healthcare fraud enforcement continues to receive substantial federal attention.
What Recent Medicare Fraud Enforcement Actions Tell Providers
The recent enforcement activity does not point to a single new compliance risk. Instead, it shows how the government’s approach to healthcare fraud is evolving.
Several themes stand out:
- Data matters. CMS has repeatedly emphasized its use of advanced data analytics to identify unusual billing patterns. Providers should be conducting their own billing and coding reviews rather than waiting for CMS to identify an anomaly first.
- Medicare Advantage remains a priority. The Aetna, Matrix, Complete Health, Monogram Health, and Villages Health matters all involved risk-adjustment diagnoses. Providers participating in Medicare Advantage arrangements should ensure that diagnoses affecting reimbursement are properly documented and supported.
- Medical necessity remains fundamental. Whether the service involves laboratory testing, home health, hospice, wound care, or another service line, documentation should establish why the service was reasonable and necessary for the individual patient.
- Referral relationships remain dangerous territory. Marketing arrangements, medical directorships, telemedicine relationships, and other financial arrangements involving referral sources continue to generate Anti-Kickback Statute and False Claims Act exposure.
- Compliance increasingly needs to happen before the claim is submitted. CMS is investing heavily in tools designed to detect suspicious activity, suspend payments, revoke enrollments, and prevent improper payments rather than simply recover them later.
When DOJ and HHS announced their False Claims Act Working Group last year, the government said it intended to combine interagency coodination with enhanced data mining to identify healthcare fraud.
The enforcement record over the past several months suggests that was more than an announcement of priorities. We are now seeing what that strategy looks like in practice.
For providers, the best response is not simply to watch the government’s next enforcement action and rather look at their own data to ensure compliance.
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