Medicare and Medicaid provide health care coverage to millions of Americans and are aggressively protected by federal and state authorities. The Department of Health and Human Services Office of Inspector General, the U.S. Attorney’s Office, and Kentucky’s Cabinet for Health and Family Services routinely pursue criminal and civil enforcement actions against health care companies, providers, and managed care organizations for fraud, waste, and abuse.
In recent years, the Department of Justice has intensified these efforts by deploying advanced data analytics and artificial intelligence to detect suspicious billing patterns. For example, the 2025 National Health Care Fraud Takedown resulted in criminal charges against 324 defendants — including 96 licensed medical professionals — for schemes involving more than $14.6 billion in intended losses. In parallel, the Centers for Medicare and Medicaid Services reported preventing over $4 billion in improper payments and suspending or revoking the billing privileges of 205 providers. Civil enforcement was also significant, with actions against more than 120 defendants resulting in tens of millions of dollars in settlements.
Recent decisions by the U.S. Court of Appeals for the Sixth Circuit reflect this aggressive enforcement posture, particularly in cases involving medically unnecessary services, deficient documentation, and inflated or false claims. Together, the cases highlighted below provide a practical roadmap for compliance —...
On Friday, April 10, 2026, the U.S. Department of Justice (DOJ) announced that International Business Machines Corporation (IBM) has agreed to pay just over $17 million to resolve allegations that ...