Heightened Scrutiny Implemented to Combat Fraud Risk in Government Programs

In a significant effort to combat health care fraud, the Department of Health and Human Services’ Office of Inspector General (OIG) has released its latest enforcement data, revealing a comprehensive picture of ongoing anti-fraud measures across the federal health care system.

The False Claims Act (FCA) remains the government’s primary civil enforcement tool against health care fraud, with most cases concluding through settlement agreements where the government alleges fraudulent conduct while defendants typically avoid formal admissions of liability.

According to newly published data covering fiscal year 2025’s first quarter, federal authorities have pursued a range of enforcement actions across their “Risk Spectrum” framework, which categorizes cases based on their severity and the responding parties’ level of cooperation.

The recent statistics show a strategic approach to enforcement, with 198 cases resolved through “no further action” determinations, representing the bulk of outcomes. These cases typically involve situations where the government determined that no additional oversight was necessary following settlement.

More serious cases led to 22 Corporate Integrity Agreements (CIAs), legally binding arrangements that require health care providers and entities to implement specific compliance measures, often including independent review organization oversight, compliance training, and regular reporting to federal authorities.

Health care industry experts note that CIAs have become increasingly sophisticated over the past decade, with more tailored provisions addressing specific risk areas rather than one-size-fits-all approaches.

“The government has evolved its approach to corporate compliance oversight,” explained Sarah Johnson, a health care compliance attorney not affiliated with the OIG. “Today’s integrity agreements often include data analytics requirements and more focused monitoring that reflects the specific violations at issue.”

At the upper end of the enforcement spectrum, the OIG imposed exclusion from federal health care programs in nine cases—the most severe administrative remedy available. Excluded providers are prohibited from receiving payment from Medicare, Medicaid, and other federal health care programs, effectively cutting them off from significant revenue streams and often forcing them out of business entirely.

The data also shows two cases placed under “heightened scrutiny,” a middle-ground approach where the government maintains close monitoring of an entity without imposing formal integrity obligations.

Notably, seven cases were resolved through the self-disclosure protocol, where providers voluntarily reported potential violations. This pathway often results in reduced penalties and obligations, reflecting the government’s policy of incentivizing transparency and cooperation.

Health care compliance officers across the country monitor these enforcement trends closely, as they provide crucial insights into OIG’s priorities and approach to different types of fraud allegations.

Industry analysts point out that the significant number of “no further action” determinations suggests the government is being selective about where it directs its limited oversight resources, focusing intensive monitoring on higher-risk providers or more egregious conduct.

The OIG evaluates risk to federal health care programs based on multiple factors, including the nature and circumstances of the conduct, the entity’s history of compliance, leadership’s involvement in or response to the issues, and the effectiveness of existing compliance programs.

These enforcement actions come amid growing concerns about health care fraud’s impact on the U.S. economy. The National Health Care Anti-Fraud Association estimates that health care fraud costs the nation approximately $68 billion annually, representing about 3% of the $2.26 trillion spent on health care.

The Risk Spectrum data will continue to be updated throughout fiscal year 2025, providing ongoing insights into enforcement patterns as the government works to protect the integrity of federal health programs and patient care.

The OIG’s approach reflects a balanced enforcement strategy that combines punitive measures for serious offenders with collaborative approaches for those demonstrating good faith efforts to correct compliance issues and prevent future violations.