Healthcare companies are subject to significant regulation and have to remain on top of compliance with these laws and how they change. Noncompliance can hurt patients and impact your healthcare business. It can also lead to investigation by federal and state agencies.
The U.S. Department of Justice (DOJ) continues to increase efforts to find and stop healthcare fraud. It can be helpful to know: what happens during a DOJ healthcare investigation?
How Do DOJ Healthcare Fraud Investigations Start?
In June 2026, efforts by the DOJ resulted in charges filed against 455 medical providers and other individuals and entities committing healthcare fraud that caused a loss of over $6.5 billion in false claims.
DOJ healthcare fraud investigations can occur for several reasons, like audits, billing discrepancies, complaints, patient information issues, whistleblowers, and investigations by other federal or state agencies. This can lead to initial contact from the agency about an investigation or a request for further information.
The U.S. Sentencing Commission reported 340 healthcare fraud cases in fiscal year 2025. You and your legal representation can assess the cause of the investigation and the specifics of the notice to determine the next ideal steps.
How you respond is crucial to the rest of the case, and you should always work with an attorney instead of trying to explain yourself to an investigator. These cases can lead to significant financial penalties, as well as other civil and criminal consequences. In fiscal year 2025, the U.S. Department of Health and Human Services Office of Inspector General reported that Medicaid Fraud Control Units recovered nearly $2 billion in civil and criminal cases.
The Process of a Healthcare Fraud Investigation
Whether you are a healthcare provider or business, understanding the potential steps of a healthcare fraud investigation can help you prepare. However, different investigations for unique violations can proceed differently, so your unique case might follow its own process. You might see steps like:
- Initial Investigation: The initial investigation is likely something you aren’t going to be made aware of. After an audit or other tip reveals a discrepancy, the DOJ will likely investigate the claim to determine if it has any basis. The agency will look for evidence in your billing statements, reimbursement claims, patient information, and other information that is relevant to the type of fraud being investigated.
- Administrative Actions: With some evidence of fraud, the agency may take actions to suspend further payor and reimbursement claims so that there is no additional financial loss.
There may also be other actions like official requests for information and a notice of the investigation. The agency may also use administrative subpoenas, interview requests, and even search warrants to continue the investigation. You may be legally required to respond to these requests. An attorney can advise you on your rights. Other parties connected to the case may also receive these requests. - Settlements or Prosecution: If there is enough evidence of fraud uncovered through the investigation, a civil or criminal case can be filed in court. Sometimes, before the court is involved, the case is handled through settlements. This can help resolve the issues of fraud with less cost for both the agency and you, while also minimizing certain other consequences that charges bring. If parties do not reach an agreement in the settlement negotiations, healthcare litigation begins.
FAQs
How Long Does a DOJ Healthcare Fraud Investigation Take?
The time a DOJ healthcare fraud investigation takes relies entirely on the specific case, its complexity, and other factors. A case may take longer when it is very complex, when a business has a lot of information to review, and if you do not cooperate with the investigation.
When you work with an attorney who is experienced in healthcare fraud investigations, they can offer you an estimate for how long your unique case may take.
What Is a Health Care Fraud Investigator?
A health care fraud investigator is an individual from an agency conducting civil or criminal investigations into healthcare companies or providers.
There are many agencies that conduct these investigations, like the Department of Health and Human Services (HHS), the HHS Office of Inspector General Office of Investigations, the Department of Justice, the Federal Bureau of Investigation, and the Food and Drug Administration. There are also state-level investigative agencies.
Why Should You Hire a Healthcare Fraud Lawyer?
You should hire a healthcare fraud lawyer to protect your interests against an investigation. An attorney can help you understand your rights and help you prepare for the investigation. If any regulations were violated, your attorney can help you understand what steps to take next. If the investigating agency is not respecting your rights, an attorney can take action to protect you. The work an attorney does during an investigation could even prevent criminal charges.
What Healthcare Fraud Crimes Does the DOJ Investigate?
Healthcare fraud crimes the DOJ investigates may include Medicaid and Medicare fraud like upcoding or submitting other types of fraudulent claims to these programs, which are prohibited under the False Claims Act.
The DOJ may also investigate violations of the Anti-Kickback Statute or Stark Law self-referral regulations. The agency investigates prescription drug fraud, billing fraud, mail and wire fraud, and licensing or certification fraud. Some of these fraud types can be investigated by multiple federal agencies.
Work With an Experienced Healthcare Fraud Attorney at Weiss Zarett Brofman Sonnenklar & Levy, P.C.
As soon as you become aware of a DOJ investigation into your healthcare business or into your practice as a healthcare provider, you need to take action and get experienced legal representation. These investigations can lead to substantial financial and reputational consequences. Rather than waiting to see what happens, you need to work with a dedicated attorney who can help you assess your situation and provide comprehensive defense strategies.
At Weiss Zarett Brofman Sonnenklar & Levy, P.C., we have years of experience in healthcare law, business law, and the regulations that govern healthcare fraud. Whether you are being audited or have received a notice of an investigation, we can act early to protect your rights. We assess your options depending on the case against you and aid you as you make informed decisions. Reach out to our firm today and learn how we can help you.
