Significant shifts in False Claims Act (“FCA”) enforcement were announced at the recent American Health Law Association (“AHLA”) Annual Meeting, as officials from the Department of Justice (“DOJ”) and Department of Health and Human Services (“HHS”) formally announced the reinstatement of their joint False Claims Act working group, signaling the agencies’ intent to have a more hands-on approach in combatting healthcare fraud. Key areas of focus will include:

• Medicare Advantage: Expect heightened scrutiny on this growing sector.
• Kickbacks and Traditional Fraud: These long-standing areas of enforcement remain high priorities.
• Overlooked Areas: A notable expansion includes violations of network adequacy requirements and the proactive use of data analytics to identify bad actors. This indicates a move beyond traditional fraud detection methods.

Shift to Proactive Government Investigations: A critical takeaway is the government’s declared intent to move beyond its historical reliance on qui tam (whistleblower) lawsuits. Officials stated they “won’t just rely on qui tams but will actively investigate new leads,” and “will start their own cases.” This marks a significant policy shift, indicating the government will initiate more of its own FCA investigations rather than waiting for whistleblowers then deciding whether to intervene.

Implications for Healthcare Organizations: This enhanced focus and proactive approach means healthcare providers, plans, and related entities should anticipate:

• Increased Government-Initiated Scrutiny: A higher likelihood of investigations even without a whistleblower complaint.
• Broader Scope of Enforcement: New areas, particularly network adequacy, will be under the microscope.
• Data-Driven Enforcement: Government agencies will utilize their vast resources to leverage data, such as AI, in order to identify potential fraud schemes.

Best Practices: To prepare for this evolving enforcement landscape, we strongly advise clients to:

· Review and strengthen compliance programs, particularly concerning Medicare Advantage, anti-kickback statutes, and network adequacy requirements.

· Conduct internal audits in these newly emphasized areas.

· Enhance internal data monitoring to proactively identify and address potential risks.