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by Kristin Rowan, Editor
Fraud, Waste, and Abuse
DOJ, HHS False Claims Act
Fraud, Waste, and Abuse has become something of a mantra within the Department of Health and Human Services (HHS). Secretary Kennedy has committed to combatting fraud, waste, and abuse within the federal healthcare system. The Department of Justice (DOJ) and HHS have a long history of working together to combat healthcare frauding under the False Claims Act (FCA).
Working Group
In furtherance of their goal to combat healthcare fraud, HHS and DOJ have formed the DOJ-HHS False Claims Act Working Group. The Working Group will include leadership from the HHS Office of General Counsel, CMS Center for Program Integrity, the Office of Counsel for the OIG, and the DOJ Civil Division.
Working Group Priorities to Combat Fraud, Waste, and Abuse
1. HHS will refer potential False Claims Act violations to the DOJ that are in line with the Working Group priority enforcement areas:
- Medicare Advantage
- Drug, device, or biologics pricing
- arrangements for discounts, rebates, service fees, and formulary placement and pricing reporting
- Barriers to patient access to care
- violations of network adequacy requirements
- Kickbacks related to drugs, medical decives, DME, and other products paid for by federal healthcare programs
- Materially defective medical devices that impact patient safety
- Manipulation of Electronic Health Records systems to drive inappropriate utilization of Medicare covered products and services
2. The Working Group will maximize collaboration to expedite investigations and identify new leads. They will leverage HHS resources using data mining and assessment of findings.
3. The Working Group will discuss implementing payment suspension according to the CMS Medicare Program Code of Federal Regulations¹
4. The Working Group will discuss whether DOJ will dismiss a whistleblower case under the U.S. Code for Civil actions for False Claims, pursuant to the DOJ Manual for Civil Fraud Litigation²
Report Fraud, Waste, and Abuse
The Working Group encourages whistleblowers to report violations of the False Claims Act within the priority areas. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to HHS at 800-HHS-TIPS (800-447-8477). Similarly, the Working Group encourages healthcare companies to identify and report such violations.
²DOJ Dismissal of a Civil Qui Tam Action. When evaluating a recommendation to decline intervention in a qui tam action, attorneys should also consider whether the government’s interests are served, in addition, by seeking dismissal pursuant to 31 U.S.C. § 3730(c)(2)(A).
¹Suspension of payment. The withholding of payment by a Medicare contractor from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists, or until the resolution of an investigation of a credible allegation of fraud.
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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.
She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com
©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com
