Straight From the Source: DOJ, OIG, and CMS on Fraud and Abuse Enforcement in 2026 and Beyond

The American Health Law Association (AHLA) Conference wrapped up today, and its closing general session brought together three federal enforcers: Kim Brandt, Deputy Administrator and COO of Centers for Medicare & Medicaid Services (CMS); Susan Gillin, Assistant Inspector General for Legal Affairs at the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG); and Brenna Jenny, Deputy Assistant Attorney General in the U.S. Department of Justice’s (DOJ) Fraud Section. AHLA CEO David Cade moderated. Across the hour, the panel previewed how the three agencies intend to coordinate fraud and abuse enforcement in 2026 and beyond, emphasizing interagency collaboration, a shift from chasing improper payments to preventing them, and the connection between program integrity and affordability.

Interagency Collaboration

Interagency collaboration was a recurring theme of the panel. Jenny described the revived DOJ-HHS False Claims Act (FCA) Working Group as a deliberate effort to share data and identify new investigative targets, rather than relying on the usual feedback loop with the qui tam bar; the group defines success as reaching untapped areas of fraud. Brandt and Gillin said the partnership lets CMS and HHS-OIG educate law enforcement on program rules and take more aggressive positions of their own. Gillin called it an “unprecedented opportunity,” and Brandt credited leadership buy-in, including from CMS Administrator Dr. Oz.

From “Pay and Chase” to “Detect and Prevent”

All three panelists framed the shift from “pay and chase” to “detect and prevent” as a priority, though Jenny cautioned that civil enforcement will always retain some pay-and-chase character. CMS now uses AI-driven “heat maps,” reviewed weekly, and is moving toward ClaimsCore — a pending procurement to replace legacy Medicare claims systems with near-real-time fraud detection at the point of payment. HHS-OIG, in turn, mines CMS program-integrity data several times a week to identify program vulnerabilities and route each issue to the agency best equipped to address it.

Affordability Meets Program Integrity

Affordability was tied directly to program integrity, and skin substitutes offered the clearest example. Because non-biological skin substitutes were paid at average sales price plus 6%, manufacturers could set launch prices that drove Medicare Part B spending from $252 million in 2019 to more than $10 billion in 2024 — a roughly 40-fold increase. CMS’ CY2026 Physician Fee Schedule final rule replaced that methodology with a flat per-square-centimeter rate, which Brandt credited with a roughly 99% cut in projected spending. Outlier-billing letters, she added, prompted 60% of recipients to stop billing for skin substitutes entirely. Brandt credited CMS’ fraud, waste, and abuse efforts with $41.9 billion in savings last year.

On the enrollment side, Brandt described three active moratoria designed to curb “whack-a-mole” fraud migration, along with the suspension of roughly half of the 1,500 hospice agencies in Los Angeles — including one organized-fraud pattern of 311 hospices tied to a single bank account.

Qui Tam and the Road Ahead

Qui tam activity continues to climb. Filings rose from 980 in FY2024 to 1,300 in FY2025, with more than 40% traceable to data miners. Jenny said DOJ welcomes the help but is launching an initiative to evaluate data miners against uniform metrics, since a statistical outlier alone is not an FCA theory. She also defended qui tam’s constitutionality, pointing to DOJ’s control over relator actions.

Asked for a single takeaway, all three panelists looked ahead. Brandt pointed to a CRUSH rule expected this fall and a longer-term ambition for a unified Medicaid enrollment system and a national provider directory spanning all fifty states. Jenny’s goal is durability — building something that outlasts the current administration. Gillin emphasized using HHS-OIG’s authority efficiently but carefully, preserving due-process protections for legitimate providers.

That’s a wrap on our coverage this year. Thanks for following along.

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