A panel of former federal prosecutors and current health care law practitioners identified key trends in health care enforcement by the Trump administration at the ABA White Collar Crime Institute in March 2026. These trends included (i) an enduring focus on waste, fraud, and abuse in the health care industry; (ii) a continued focus on Medicare Advantage and a newer focus on gender transition procedures for minors; and (iii) the ever-increasing use of data analytics to prosecute cases. The panel also focused on recent appellate decisions — such as United States v. Schena (9th Circuit) — and its potential implications for providers making payments for marketing and advertising services.
Continued Focus on Waste, Fraud, and Abuse
The Department of Justice (DOJ) reported that its 2025 National Health Care Fraud Takedown resulted in criminal charges against hundreds of defendants in various health care fraud schemes the DOJ reported involved over $14 billion in intended loss, which was more than double the prior record of $6 billion. In the meantime, the DOJ reported that civil False Claims Act (FCA) settlements and judgments exceeded $6.8 billion in fiscal year 2025. The majority of recoveries came from the health care industry, and all indications are that the government expects this trend to continue.
In May 2025, Matthew Galeotti, then-Head of the Criminal Division, released a new white collar enforcement plan outlining the government’s principle priorities. The plan places “waste, fraud, and abuse” — including health care fraud and fraud involving federal programs and procurement that impact public funds — at the top of the government’s enforcement agenda, ahead of areas such as trade and customs fraud, including tariff evasion.
On July 2, 2025, the Department of Health and Human Services also announced the creation of a False Claims Act Working Group to deepen focus on FCA enforcement in the health care industry. The DOJ reported that more than 1,200 qui tam whistleblower suits were filed in federal fiscal year 2025 — a record — and the overwhelming majority were tied to the health care industry. Even as the Trump administration streamlines the government workforce, health care enforcement will remain a priority area for DOJ staff.
Highlighted Focus Areas
Over the past year, the government has signaled a strong emphasis on enforcement related to common areas like Medicare Advantage and more novel areas such as gender transition procedures for minors.
Medicare Advantage
On May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) announced a major overhaul of its Risk Adjustment Data Validation (RADV) audit program for Medicare Advantage plans. The initiative would expand audits from a limited sample of roughly 60 contracts to all eligible Medicare Advantage contracts annually, accelerate completion of backlogged audits for payment years 2018–2024, and deploy enhanced technology and additional personnel to strengthen overpayment detection and increase overall audit activity. CMS also indicated plans to partner with HHS-OIG to recover overpayments from prior audits.
To support the initiative, CMS planned to increase its coding staff from approximately 40 to 2,000 by September 1, 2025, enabling manual review of flagged diagnoses for accuracy. However, that effort was derailed by a 2025 Northern District of Texas decision in Humana Inc. v. Becerra, which vacated CMS’s 2023 RADV Final Rule on procedural grounds and suspended its authority to extrapolate RADV audit findings across an entire contract population. The ruling has temporarily stalled CMS’s large-scale audit and recovery efforts, but the agency is expected to continue prioritizing Medicare Advantage enforcement in the coming years under the Trump administration (for more detailed analysis on Medicare and Medicare Advantage enforcement priorities, see our previous publication on Health Care & Life Sciences Enforcement Trends here).
Gender Transition Procedures for Minors
A growing area of enforcement for the Trump administration involves providers offering gender transition procedures to minors. On January 28, 2025, Trump issued an executive order called “Protecting Children from Chemical and Surgical Mutilation,” stating that the federal government will not fund or support such procedures and will enforce applicable prohibitions. Former United States Attorney General Pam Bondi later issued a memo directing the DOJ’s Civil Division to investigate potential False Claims Act violations tied to these services. In April 2025, CMS also instructed state Medicaid programs to cease funding gender-affirming procedures for minors, referencing sterilization regulations as authority.
Some health care providers have already curtailed gender transition services due to the litigation risk and public scrutiny. Some insurance companies and hospitals have received subpoenas seeking data about the provision of medical services to transgender youth. Providers receiving government funds should review compliance certifications closely, as False Claims Act exposure in this area creates enterprise-level risk demanding board-level attention.
Increased Use of Data Analytics
The government continues to increase its use of data analytics in False Claims Act enforcement. Key data sets include Medicare and Medicaid claims data, provider utilization files and specialty comparators, quality metrics for Medicare Advantage (e.g., HEDIS), and prescription monitoring data. The data often is (i) used to identify patterns, anomalies, or risk signals; (ii) often performed before any complaint or subpoena is issued; (iii) used to predict fraud risk, guide audits, and support statistical extrapolation; and (iv) utilized as a measure of both descriptive analytics and predictive analytics.
Data mining is now inseparable from False Claims Act enforcement. Providers should expect a deeper reliance on predictive models and anomaly detection by the government, and lawyers must also understand the data to effectively defend their clients from enforcement actions. Although data alone cannot prove a FCA case, it often supports arguments including that a provider “knew or should have known” about improper billing. Providers should utilize their own analytical tools to detect and remediate potential risks before government intervention.
Recent Case Development (Schena in 9th Circuit)
The panel also discussed United States v. Schena (9th Circuit, July 11, 2025), which addressed percentage‑based compensation for marketing clinical laboratory tests. The defendant laboratory paid independent marketers commissions tied to test volume, including efforts to persuade less‑experienced physicians or those outside the allergy specialty of the claimed superiority of its allergy and diagnostic blood‑testing services. The DOJ alleged that those payments violated the Eliminating Kickbacks in Recovery Act (EKRA) of 2018 (18 U.S.C. § 220) because they were designed to induce referrals. Schena is also notable as the first appellate decision to interpret EKRA, providing the initial judicial guidance on how its prohibitions apply to marketing and compensation practices.
The Ninth Circuit upheld the convictions, clarifying the scope of EKRA’s application. The court found that paying marketers can create criminal exposure when compensation is intended to generate or influence referrals through false, misleading, or fraudulent representations. However, it emphasized that a percentage‑based compensation structure, without evidence of improper inducement or fraud, does not by itself violate EKRA.
Schena confirms that EKRA’s scope extends beyond traditional doctor‑to‑doctor arrangements and can apply to third‑party marketing or promotional relationships. Health care organizations should therefore evaluate commission or incentive‑based marketing practices for potential referral inducement risk, ensure that their promotional statements are truthful and non‑misleading, and adopt compliance controls to monitor these arrangements.
Conclusion
The Trump administration remains focused on pursuing and punishing health care fraud. It continues to view fraud, waste, and abuse of government funds as a key priority. The administration has the data analytics tools to complement its efforts. Recent developments serve as a reminder that the government’s enforcement authority is not limited to physicians and direct healthcare providers, but rather it can also reach indirect suppliers and other participants whose activities influence the delivery or billing of patient services. Health care providers and suppliers should take note of these developments and implement appropriate compliance measures with assistance from experienced legal counsel.
