Healthcare Fraud Enforcement Trends to Expect in 2026

Key Takeaways

• AI-driven oversight will accelerate enforcement. DOJ, HHS-OIG, and CMS are scaling machine learning tools that rapidly flag outlier billing, telehealth spikes, and risk-adjustment irregularities — increasing the speed and scope of investigations.
• False Claims Act activity will intensify. Expect expanded FCA liability theories, especially in Medicare Advantage risk-adjustment, along with more parallel civil/criminal actions and larger Stark/AKS-related settlements.
• Telehealth and pharmacy operations face heightened scrutiny. Virtual-care billing, remote prescribing, and pharmacy/PBM practices tied to opioids, specialty drugs, and formulary manipulation remain top enforcement priorities.
• Value-based care arrangements carry growing fraud-and-abuse risks. Enforcement agencies are targeting improper incentive structures, upcoding, and quality-metric manipulation across APMs, ACOs, and Medicare Advantage plans.

Healthcare Fraud Enforcement: What’s Driving 2026 Priorities

As administrations change, government priorities shift and federal resources are allocated in accordance with the current administration’s goals and positions. Historically what has not changed is the government’s emphasis on combatting waste, fraud, and abuse in the healthcare industry. This past year has been no different. From the Department of Justice (“DOJ”) and Department of Health and Human Services’ (“HHS”) announcement of a new False Claims Act (“FCA”) Working Group, to highly publicized False Claims Act cases against a pharmacy chain related to enforcement efforts arising out of the opioid crisis, to cases against large health insurers related to the Medicare Advantage program, the government continues to provide resources to address alleged healthcare fraud.

In 2026, healthcare organizations face an enforcement environment that is more data-driven, coordinated, and technologically sophisticated than ever. Federal and state agencies continue to prioritize fraud, waste, and abuse — particularly as healthcare spending, digital-health adoption, and value-based care models accelerate. Providers, suppliers, and investors should take a proactive posture to mitigate exposure and prepare for heightened scrutiny.

Some of the key fraud-enforcement trends expected to affect the compliance landscape in 2026 include:

AI-Enabled Enforcement and Advanced Analytics

Federal enforcement agencies — including the DOJ, HHS-OIG, and CMS — are expanding use of machine learning tools to analyze claims, referral patterns, and prescribing data. This may result in:

• Faster case development through real-time anomaly detection in Medicare and Medicaid data
• Broader identification of suspicious billing clusters, such as outlier telehealth usage or unusually high service intensity
• Predictive models that identify providers at risk for potential FCA violations even before whistleblowers surface issues

Continued Aggressive Use of the False Claims Act

The government’s reliance on the FCA — especially in cases involving medically unnecessary services, kickbacks, and improper billing — will remain strong in 2026. Key themes include:

• Expanded theories of liability, particularly around inaccurate risk-adjustment submissions in Medicare Advantage
• Increased parallel proceedings, with civil, administrative, and criminal actions running simultaneously
• High-value settlements centered on Stark Law and Anti-Kickback Statute (“AKS”) violations

Telehealth and Virtual-Care Scrutiny Remains High

Telemedicine has matured beyond its pandemic origins, but enforcement agencies continue to scrutinize:

• “Virtual-only” providers and high-volume telehealth billing models
• Remote prescribing practices, especially for controlled substances
• Cross-state licensure and compliance with digital-health supervision rules
• Marketing arrangements involving third-party telehealth platforms

Enforcement Focus on Pharmacy, PBMs, and Controlled Substances

Pharmacies, pharmacy benefit managers (“PBMs”), and prescribing clinicians remain top enforcement targets, with emphasis on:

• Opioid-related prescribing patterns and diversion risks
• Prior authorization and formulary manipulation
• Specialty-drug billing and reimbursement
• Compounded medication arrangements

Compliance Risks in Value-Based and Alternative Payment Models

As value-based care expands, so do fraud-and-abuse challenges:

• Improper incentive structures in provider-payer arrangements
• Risk-adjustment upcoding allegations in Medicare Advantage and ACO settings
• Quality-metric manipulation, including inflated reporting of outcomes or utilization reductions

Increased State-Level Activity

States are stepping up enforcement in Medicaid and commercial-payer markets, including:

• Mandatory reporting of suspected fraud events
• Enhanced oversight of managed-care organizations
• State-level AI fraud-detection initiatives
• More aggressive licensing-board investigations into clinical practices

Preparing for 2026 Compliance Readiness

Proactive compliance planning in 2026 will be far less costly than responding to a government investigation, even if the allegations are ultimately determined to be meritless. To reduce risk in the evolving enforcement climate, organizations should:

• Conduct regular compliance audits targeting high-risk service lines
• Update telehealth and digital-health policies
• Validate coding, documentation, and risk-adjustment practices
• Reassess Stark Law and AKS compliance in all financial relationships
• Implement or enhance internal analytics and monitoring tools
• Train clinical and administrative staff on emerging enforcement priorities