In past years, federal and state authorities typically initiated healthcare fraud investigations based on whistleblower complaints and audits. While that still occurs, the model is changing. Federal enforcement agencies are increasingly using sophisticated data analytics, artificial intelligence, and coordinated investigative efforts to identify potential fraud.
The Department of Justice (DOJ), the U.S. Department of Health and Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS) have invested in technology that can identify unusual billing patterns, referral relationships, prescribing habits, and coding trends. In 2025, the DOJ announced the development of the Health Care Fraud Data Infusion Center for improving healthcare fraud detection and enforcement by combining data, analytics, and intelligence from multiple federal agencies.
In June, the DOJ reported results under the 2026 National Health Care Fraud Takedown, a nationwide enforcement action that resulted in charges against 455 defendants (including 90 physicians and other licensed practitioners) and more than $6.5 billion in alleged false claims, including alleged schemes involving laboratory testing, durable medical equipment, wound care products, behavioral health services, and telehealth. Medicaid programs were a major focus, which involved more than $518 million in alleged false claims and 295 defendants charged with fraud. As part of the Takedown, CMS revoked the billing privileges of 1,403 providers, and HHS-OIG pursued more than 1,400 exclusions and civil monetary penalty actions.
In Oklahoma, the Takedown included an indictment against DME company operators charged with submitting more than $27 million in fraudulent claims to TRICARE based on over 650,000 separate in-person services that the government alleges were not provided. Other Oklahoma cases reported are an indictment against the owner of three pharmacies charged with 16 counts of healthcare fraud for submitting false claims for reimbursement for COVID-19 tests and federal and Oklahoma Medicaid false claim actions against an individual speech-language pathologist who allegedly submitted more than $2.5 million in claims. Additionally, the Oklahoma AG’s Medicaid Fraud Unit secured a conviction against a Tennessee counselor and a guilty plea from a behavioral analyst for submission of fraudulent Oklahoma Medicaid claims.
Healthcare providers should continue to engage in compliance efforts to prevent, detect, and correct any billing and coding issues. If errors are found, claims should be promptly refunded to Medicare, Medicaid, and other government programs. Based on the Takedown, providers should update compliance initiatives to use “quantitative” monitoring and analyze claims volume by provider (and any significant increases), utilization rates by CPT code, comparison of providers against peers, and denial rates. CMS publishes comparative and benchmarking data that providers can use to monitor billing, coding, utilization, reimbursement, and outlier risks. Modern analytic tools can use AI to scan electronic health and billing records to identify potential issues in documentation of medical necessity and identify concerns in billing or coding patterns. Should there be an enforcement action, the DOJ will give credit to a healthcare provider with an effective compliance program, which can mean lower monetary penalties, greater likelihood of a settlement, and less risk of a prosecution.
This article appeared in the September 10, 2026, issue of The Journal Record. It is reproduced with permission from the publisher.
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