The schemes federal prosecutors charge most often are billing fraud, illegal kickbacks, telehealth and genetic testing arrangements, and more recently, wound care allografts. Each of these shows up year after year in the Justice Department’s national health care fraud takedowns.
Enforcement has grown sharply, and so has the risk for providers who never set out to break a rule. If your practice or hospital is under investigation, a healthcare fraud defense lawyer at Griffin Durham Tanner & Clarkson LLC can tell you what the government is actually looking at.
Federal healthcare fraud enforcement is at record levels
In June 2026, the Justice Department charged 455 defendants, including 90 doctors and other licensed medical professionals, in schemes involving more than $6.5 billion in alleged false claims. The 2025 takedown a year earlier charged 324 defendants over $14.6 billion in intended losses.
These are coordinated national operations rather than isolated cases. The 2026 action reached 56 federal districts and 45 states and territories.
Charges aren’t the only exposure. Along with that takedown, the Centers for Medicare & Medicaid Services (CMS) suspended 1,079 providers and revoked billing privileges for another 1,403. Those actions are administrative, and they don’t require a conviction or even a charge.
Several agencies work these cases together. DOJ’s Health Care Fraud Unit (HCFU) brings the prosecutions, while HHS’s Office of Inspector General, the FBI, the DEA, and state Medicaid Fraud Control Units run the investigations behind them.
Phantom billing and upcoding
Billing fraud remains the most commonly charged conduct. Phantom billing means submitting claims for services that never happened, like an appointment the patient missed or lab work that was never run. Upcoding means billing a real service at a higher level than what was provided, so a routine office visit gets submitted as a complex one.
Related theories come up constantly, including double billing the same service and unbundling, which means billing separately for procedures meant to be submitted together at a lower combined rate.
Most of these cases are built from claims data rather than from witnesses, which means the government often arrives already holding years of your billing history.
Kickbacks and illegal referral arrangements
The Anti-Kickback Statute makes it a crime to pay or receive anything of value in exchange for referrals or for generating business paid for by a federal healthcare program. Payments, gifts, free services, and inflated consulting fees have all been charged as kickbacks.
The Stark Law covers overlapping ground but works differently, since it’s civil and doesn’t require proof of intent. The same arrangement can draw a criminal charge and a civil False Claims Act (FCA) case at once, built from the same records.
Telehealth and genetic testing schemes
Telehealth expanded access to care and also opened a channel prosecutors now watch closely. The pattern that gets charged usually involves a provider signing orders for patients they never meaningfully evaluated, often for genetic testing or durable medical equipment, in volumes no ordinary practice would generate.
Marketing companies frequently sit at the center of these cases. They recruit patients through call centers and mailed swab kits, then route the orders to physicians who are paid per signature. The physician is often charged alongside the marketers, even when they had no view of the larger operation.
Wound care allografts and skin substitutes
Allografts drew the most attention in 2026. These are skin and amniotic tissue products used on chronic wounds, and reimbursement climbed high enough that billing outran any plausible medical need. Providers billed Medicare more than $4 billion for a single company’s allografts between December 2021 and June 2024.
Eleven defendants were charged across six districts. The theories track the older ones. Products were allegedly billed for wounds that didn’t call for them, and in quantities exceeding the size of the wound. Kickbacks to the providers who applied them are alleged in most of the cases.
CMS has since cut Medicare’s payment to $127 per square centimeter, effective January 2026. Providers who relied on a manufacturer’s coding guidance have been swept into these cases alongside the people who designed the schemes.
How these investigations usually begin
Rarely with an agent at the door. Most start quietly, in one of a few ways.
CMS and the private companies that process Medicare claims compare your billing against everyone else in your specialty. The HCFU runs a Data Fusion Center staffed with analysts from HHS-OIG and the FBI, and it was that team’s analysis that detected the allograft billing spike and triggered the prosecutions. Former employees are the other common origin, since the FCA lets a whistleblower file a case under seal that a provider won’t learn about for months.
What you’ll likely see first is paper. That’s usually a subpoena or a civil investigative demand. Sometimes it’s just a records request from a Medicare contractor, which means the same thing. How you handle that first document tends to matter more than anything that follows.
Talk to a healthcare fraud defense lawyer
A criminal case isn’t the only exposure. A conviction, and in some circumstances a civil resolution, can trigger exclusion from Medicare and Medicaid along with a separate proceeding before your licensing board. Those run on their own timelines, and they can be addressed while the criminal matter is still open.
Griffin Durham Tanner & Clarkson LLC is a trial boutique led by former federal prosecutors who handled these cases from the other side. Call our office (404) 891-9150 to request a consultation.
