The U.S. Department of Justice has completed its 2025 National Health Care Fraud Takedown, which resulted in criminal charges against 324 defendants for their alleged participation in various healthcare fraud schemes involving more than $14.6 billion.
The defendants included 96 doctors, nurse practitioners, pharmacists and other licensed medical professionals, in 50 federal districts and 12 State Attorneys General's Offices across the U.S., the DOJ said.
The government seized more than $245 million in cash, luxury vehicles, cryptocurrency and other assets as part of its efforts.
At the same time, the Centers for Medicare and Medicaid Services said it successfully prevented over $4 billion from being paid in response to false and fraudulent claims, and that it suspended or revoked the billing privileges of 205 providers in the months leading up to the takedown.
Civil charges against 20 defendants for $14.2 million in alleged fraud, as well as civil settlements with 106 defendants totaling $34.3 million, were also announced as part of the effort.
WHAT'S THE IMPACT
Twenty-nine defendants were charged for their roles in transnational criminal organizations alleged to have submitted more than $12 billion in fraudulent claims to America's health insurance programs.
Charges were also filed in the District of Arizona and the District of Nevada against seven defendants, including five medical professionals, in connection with approximately $1.1 billion in fraudulent claims to Medicare and other healthcare benefit programs for amniotic wound allografts.
As alleged, certain defendants targeted vulnerable elderly patients, many of whom were receiving hospice care, and applied medically unnecessary amniotic allografts to these patients' wounds. Many of the allografts allegedly were applied without coordination with the patients' treating physicians, without proper treatment for infection, to superficial wounds that did not need the treatment, and to areas that far exceeded the size of the wound. Certain defendants allegedly received millions in illegal kickbacks from the fraudulent billing scheme.
Seventy-four defendants, including 44 licensed medical professionals, were charged across 58 cases in connection with the alleged illegal diversion of over 15 million pills of prescription opioids and other controlled substances. For example, five defendants associated with one Texas pharmacy were charged with the unlawful distribution of over 3 million opioid pills.
The Drug Enforcement Agency has also said that it charged 93 administrative cases seeking the revocation of pharmacies, medical practitioners, and companies' authority to handle or prescribe controlled substances.
Also in the takedown, 49 defendants were charged in connection with the submission of more than $1.17 billion in allegedly fraudulent claims to Medicare resulting from telehealth and genetic testing fraud schemes. In one instance, in the Southern District of Florida, prosecutors charged an owner of telehealth and durable medical equipment companies with a $46 million scheme in which Medicare beneficiaries were allegedly targeted through deceptive telemarketing campaigns, and then fraudulent claims were submitted to Medicare for durable medical equipment and genetic tests for those beneficiaries.
Other cases charge an additional 170 defendants with various other healthcare fraud schemes involving over $1.84 billion in allegedly false and fraudulent claims to Medicare, Medicaid and private insurance companies for diagnostic testing, medical visits, and treatments that were medically unnecessary, provided in connection with kickbacks and bribes, or never provided at all.
THE LARGER TREND
The DOJ said it's working with the Health and Human Services' Office of the Inspector General and the FBI to create a Health Care Fraud Data Fusion Center that would allow the agencies to leverage experts and technologies such as artificial intelligence, cloud computing and advanced analytics to detect fraud.
"Joining forces with data analysts from HHS-OIG, FBI and other partners will increase efficiency, detection and rapid prosecution of emerging healthcare fraud schemes," the DOJ said.
"This record-setting Health Care Fraud Takedown delivers justice to criminal actors who prey upon our most vulnerable citizens and steal from hardworking American taxpayers," Attorney General Pamela Bondi said in a statement. "Make no mistake – this administration will not tolerate criminals who line their pockets with taxpayer dollars while endangering the health and safety of our communities."
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.