Fraud & Abuse

close up shot, accountant working with laptop reviewing the company's accounts and financial documents on desk

This is the third in a six-part series on incentive design, deal structure, and how these issues surface in transactions and enforcement. Other relevant topics will be discussed in our upcoming presentation, Physician Owner Mindset, Compliance Guardrails: Growth Without the Gotchas, to be given at the American Alliance of Orthopaedic Executives on Tuesday, April 21.

Deal teams spend months building a story.
Quality of earnings.
Payer mix.
Capacity.
Growth.

The story lives in a deck, a model, and a set of emails. The material is often pulled together fast, under deadlines. It gets recycled and edited by multiple people.

A single loose phrase can change how a buyer views risk, how counsel drafts reps, and how quickly a process moves.

In some cases, it reads as if the business plan depends on referrals.

That is avoidable.

finance accounting concept. pen and calculator on table

This is the second in a six-part series on incentive design, deal structure, and how these issues surface in transactions and enforcement. Other relevant topics will be discussed in our upcoming presentation, Physician Owner Mindset, Compliance Guardrails: Growth Without the Gotchas, to be given at the American Alliance of Orthopaedic Executives on Tuesday, April 21.

Productivity-based compensation is common in physician organizations. It is also where many problems begin.

Start with the formula. Then focus on the carve-outs, the discretionary payments, and the year-end cleanups.

This is the first in a six-part series on incentive design, deal structure, and how these issues surface in transactions and enforcement. Other relevant topics will be discussed in our upcoming presentation, Physician Owner Mindset, Compliance Guardrails: Growth Without the Gotchas, to be given at the American Alliance of Orthopaedic Executives on Tuesday, April 21.

Sign at the United States Department of Justice in Washington, DC

In June 2025, the Department of Justice (DOJ) announced its 2025 National Health Care Fraud Takedown, marking the largest coordinated healthcare fraud enforcement action in DOJ history. The sweep included charges against a range of actors including alleged transnational criminal organizations, providers of allegedly fraudulent wound care, alleged prescription opioid traffickers, alleged telemedicine, and genetic testing fraudsters, among others. DOJ also introduced the creation of a Health Care Fraud Data Fusion Center, designed to enhance the detection, investigation, and prosecution of healthcare fraud.

Laboratory Testing

In June 2025, the U.S. Department of Health and Human Services Office of Inspector General (OIG) announced a new item in its Work Plan: “Medicare Payments for Clinical Diagnostic Laboratory Tests in 2024.” This annual review, mandated by the Protecting Access to Medicare Act of 2014 (PAMA), focuses on analyzing the top 25 laboratory tests by Medicare expenditures for the previous calendar year. For clinical laboratories and healthcare providers, this announcement signals the need to pay close attention to billing practices, compliance programs, and potential audit risks.

Sign at the United States Department of Justice in Washington, DC

On July 2, 2025, the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) announced the creation of the DOJ-HHS False Claims Act Working Group, a high-level interagency initiative aimed at strengthening the government’s civil enforcement of the False Claims Act (FCA) in the healthcare space. While the DOJ and HHS have long worked together to combat fraud, this Working Group marks a formalized, tightly coordinated effort focused on high-impact enforcement areas.

A recent False Claims Act (FCA) litigation—Jensen ex rel. United States of America v. Genesis Laboratory—highlights critical compliance risks for laboratories. This case reinforces the need for laboratories to ensure adherence to federal regulations governing medical necessity, lab requisition practices, and the Anti-Kickback Statute (AKS).

Sign at the United States Department of Justice in Washington, DC

On February 25, 2025, the U.S. Department of Justice filed a False Claims Act (FCA) complaint against an Idaho home health agency and its owner, alleging that a series of Paycheck Protection Program (PPP) loan applications were fraudulent because the home health agency did not disclose in the applications that the home health agency was making improper claims to Idaho Medicaid at the time it applied for the loans.

On August 26, 2024, the United States Attorney’s Office for the District of Montana filed a False Claims Act (FCA) complaint against a Montana oncologist, alleging that the oncologist’s busy schedule led to excessive claims that violated the FCA. The complaint is unusual in that its chief theory is the amount of time the oncologist spent with patients, relative to what the Justice Department claims is the standard practice of other oncologists. In that respect, the complaint is a warning sign to busy physicians across the country.

This blog post begins by explaining how this Montana oncologist found himself on the Justice Department’s radar—a self-disclosure by the health system that previously employed the oncologist—before discussing what the Justice Department is alleging against the oncologist, as well as what other physicians should learn from this lawsuit.

On June 13, 2024, the Justice Department announced arrests in what it called the nation’s first criminal case against digital health company executives over allegations that those executives caused illegal prescriptions for controlled substances to be ordered by way of telehealth visits.

While the Justice Department has previously brought charges in telehealth cases involving things like orthotic braces or genetic testing, a case against digital health executives involving telehealth-prescribed controlled substances is a first.