Healthcare fraud continues to plague providers, managed care, and drug companies.  $5.7 billion of the $6.8 billion recovered by DOJ was generated from the healthcare industry.  There is a bottomless pit of possible targets.  DOJ’s only constraint is its resources assigned to prosecute FCA cases in the healthcare industry. 

DOJ focused on three major areas: Managed Care, Prescription Drugs, and Medically Unnecessary Care.  In Managed Care, DOJ pursued cases focused on the Medicare Advantage (or Medicare Part C) program.  As Medicare Part C is now the largest component of Medicare, both in terms of federal dollars spent and the number of beneficiaries impacted, the work of the Justice Department in this area is of critical importance.

Some examples include:

Independent Health Corporation agreed to pay up to $98 million to resolve false claims allegations of unsupported and invalid diagnosis codes submitted for Medicare Advantage Plan enrollees to increase payments from Medicare. Independent Health retrospectively searched medical records and queried physicians for information to add improper diagnoses for enrollees. 

Seoul Medical Group Inc. and its subsidiary Advanced Medical Management Inc., and its former president and owner agreed to pay over $60 million to resolve allegations that they caused the submission of false diagnosis codes for spinal conditions that patients did not have in order to increase payments from the Medicare Advantage program.

The Justice Department intervened in a qui tam against national insurers Aetna Inc., Elevance Health Inc., and Humana Inc., as well as three insurance brokers eHealth Inc., GoHealth, Inc., and Select Quote Inc. The insurers agreed to pay hundreds of millions of dollars in illegal kickbacks to the brokers in exchange for steering Medicare beneficiaries to enroll into the insurers’ Medicare Advantage plans, regardless of the suitability of those plans for the beneficiaries. In addition, the insurers refused to sell plans of insurers that did not pay them kickbacks.

With respect to Aetna and Humana, the Department alleged that they each conspired with the brokers to avoid enrollment of Medicare beneficiaries with disabilities, which the insurers perceived to be less profitable for them.

As to prescription drugs, DOJ pursued cases related to drug pricing, drug dispensing, and illegal kickbacks.

Teva Pharmaceuticals USA Inc., the largest generic drug manufacturer in the country, agreed to pay $425 million to resolve allegations that it violated the False Claims Act by paying copays for Medicare patients for the multiple sclerosis drug Copaxone while steadily raising the drug’s price. 

Teva further agreed to pay $25 million to resolve allegations that it conspired with other generic drug manufacturers to fix prices for certain drugs and that the benefits Teva received under its price fixing scheme constituted illegal kickbacks. 

A unanimous jury found Omnicare, the country’s largest long-term care pharmacy, and its parent CVS liable for fraudulently dispensing drugs without valid prescriptions to elderly and disabled people in assisted living facilities and other residential long-term care facilities.  After a four-week trial, the jury found that Omnicare and CVS billed Medicare, Medicaid, and TRICARE for over three million false claims.  In August 2025, the court entered a judgment including treble damages and penalties for a total amount of $948.8 million. 

Medisca Inc. agreed to pay $21.75 million to resolve allegations concerning the establishment of false and inflated Average Wholesale Prices (AWPs) for two ingredients used in compound prescriptions.

Gilead Sciences, Inc. agreed to pay $176 million for offering and paying kickbacks in the form of honoraria payments, meals, and travel expenses to healthcare practitioners who spoke at or attended Gilead speaker events to induce them to prescribe certain Gilead HIV drugs.  As part of the settlement, Gilead admitted it paid many high-volume prescribers of HIV drugs tens or hundreds of thousands of dollars in honoraria payments to prepare and present as HIV speakers. 

Biohaven Pharmaceutical Holding Company Ltd. (Biohaven), a Pfizer subsidiary, agreed to pay $59.7 million to resolve allegations that, prior to Pfizer’s acquisition of the company, Biohaven paid kickbacks to health care providers to induce prescriptions.  The government alleged that Biohaven selected and paid certain health care providers with the intent that the speaker honoraria and meals would induce them to prescribe its drug.  

The United States pursued several pharmacies for filling prescriptions for controlled substances that lacked a legitimate medical purpose, were not valid and/or were not issued in the usual course of professional practice. In those matters, the government alleged that the prescriptions included those for dangerous and excessive quantities of opioids, prescriptions for early refills of opioids and prescriptions for the especially dangerous and abused combination of drugs known as the “trinity,” which is made up of an opioid, a benzodiazepine and a muscle relaxant. The government filed a complaint against CVS and various subsidiaries asserting such allegations. The government also filed a complaint against Walgreens and various subsidiaries, which Walgreens resolved, agreeing to pay up to $350 million. 

DOJ continued to target healthcare companies for false claims arising from medically unnecessary services and substandard care that puts at risk the health and safety of vulnerable patient populations. 

The United States filed a complaint against Vohra Wound Physicians Management LLC (Vohra) and its founder and majority owner, Dr. Ameet Vohra, for allegedly causing the submission of false claims to Medicare for overbilled and medically unnecessary wound care services.  The United States alleged that the defendants engaged in a nationwide scheme to falsely bill Medicare for surgical debridements – procedures to remove dead or unhealthy tissue that could impede wound healing – to maximize revenue.  The defendants subsequently agreed to pay $45 million to settle this matter.

Oroville Hospital agreed to pay $10.25 million to resolve allegations that it billed Medicare and Medicaid for medically unnecessary inpatient hospital admissions, billing for more expensive inpatient hospital admissions when observation status or outpatient care was appropriate.  The government further alleged that the hospital illegally incentivized inpatient admissions by paying financial bonuses to doctors who worked full time at the hospital and were in a position to influence whether patients were admitted to the hospital.