Although much of the content of the prosecutions is the same as in past years (e.g. wound care, opioids), Medicaid fraud—long the province of state Medicaid Fraud Control Units (“MFCUs”)—featured prominently in the 2026 Takedown. DOJ claims to have charged the largest number of Medicaid fraud defendants and Medicaid fraud loss in DOJ history: 295 defendants and over $518 million in alleged false claims submitted to Medicaid. Per the DOJ press release, the MFCUs of all 50 states participated, the highest number ever.

• Accelerated FCA Investigative Timeline: The U.S. Department of Justice (DOJ) is taking new steps to implement the directives of Executive Order 14395 of March 16, 2026, “Establishing the Task Force To Eliminate Fraud,” by expediting the review for newly filed False Claims Act (FCA) qui tam actions involving federally funded state-administered benefits programs. The May 27, 2026, memorandum from Assistant Attorney General Brett A. Shumate (“Shumate Memo”) states that all newly filed state-administered benefits program fraud qui tam actions will now be reviewed by DOJ in 60 to 120 days after filing to determine if the government will continue its investigation, permit the whistleblower to proceed, or act to dismiss the case.
• DOJ Reaffirmation of Relator Authority: The Shumate Memo reaffirms DOJ’s position that whistleblowers may “stand in the shoes” of the government and indicates that the agency will let relators lead litigation subject to DOJ’s “oversight and ultimate control.”
• Automatic Criminal and Administrative Referrals: New benefits program fraud qui tam matters will be automatically referred to the Criminal Division and/or the National Fraud Enforcement Division for evaluation of potential criminal violations and to the affected agency for potential administrative action, including payment suspension.

DOGE has been mining Medicaid and Medicare data for the past year. The newly released dataset aggregates provider-level claims data by billing or servicing provider, procedure code, and month, and covers fee-for-service, managed care, and CHIP claims from 2018-2024.

The ACCESS Model tests whether a new payment methodology, Outcome Aligned Payments (OAPs) can better support technology-enabled care, improve health outcomes, and lower overall Medicare spending for high-prevalence, high-cost chronic conditions that affect more than two-thirds of people enrolled in Medicare.

The ACCESS Model will focus on chronic conditions including high blood pressure, diabetes, chronic musculoskeletal pain, and depression.

Judge Crenshaw weighed in Nolan whether the relators, co-owners of Pathologists Laboratory P.C. (“PLPC”), had plausibly alleged that: 1) defendant HCA Healthcare Inc. (“HCA”) solicited or received “remuneration” for purposes of an AKS violation; and 2) PLPC or the second lab submitted claims “resulting from” an illegal kickback for purposes of a False Claims Act (FCA). He ultimately determined that the relators had not, in fact, plausibly alleged that HCA either solicited or received “remuneration” for purposes of the AKS.

Discover how the “Food as Medicine” movement is reshaping health care and what it means for patients, providers, and the future of wellness.

On this episode, special guests Noah Voreades of OLIPOP and Ivan Wasserman of Amin Wasserman Gurnani join Epstein Becker Green attorneys Jessika Tuazon and Ada Peters to explore how food is being integrated into health care to prevent and manage chronic diseases.

MFCUs—which investigate and prosecute statewide Medicaid provider fraud, and beneficiary abuse and neglect—recovered $1.4 billion in FY 2024, which equates to $3.46 for every $1 spent. Criminal recoveries were the highest amount in the past 10 years, $961 million, and more than double the rolling 5-year average. HHS OIG attributes this massive increase to the California MFCU, which recovered $513 million on its own.

Of particular note, the CY 2026 Rate Announcement includes a plan payment increase that is up more than $25 billion from its original proposal and continues the three-year phase-in of the move to the V28 risk adjustment model. This came just days after CMS issued the 2026 Final Rule. Created under a sharply different political landscape, the 2026 Final Rule departs from the Proposed Rule of November 26, 2024 (“2026 Proposed Rule”) in a number of ways.  

As we predicted in our previous Insight, the Trump Administration chose not to finalize some aspects of the 2026 Proposed Rule. The 2026 Final Rule balked at a number of proposals—owing at least in part to Executive Order 14192 of January 31, 2025, “Unleashing Prosperity Through Deregulation,” which was cited by CMS. With deferrals listed at 90 FR 15795 and 15892, the 2026 Final Rule is perhaps notable for

But on April 10, CMS published a State Medicaid Director Letter stating CMS “does not anticipate approving new state proposals of section 1115 demonstration expenditure authority for federal DSHP or DSIP funding or renewing existing Section 1115 demonstration expenditure authority for federal DSHP or DSIP funding, including when current DSHP or DSIP authority concludes before the expiration date of the demonstration.”

The reasoning? CMS has concluded that these programs were funded entirely without Medicaid funds prior to their approval, and the additional federal funds that they received “does not render these programs as integral components of section 1115 demonstration programs.” CMS now frowns on the notion that the federal government should: (i) share in the costs of funding these state programs; (ii) reduce state obligations with respect to services that CMS deems not otherwise covered by Medicaid; (iii) and “[serve] primarily as a financing mechanism for states, resulting in increased federal expenditures.”

How significant are some of these changes, and how might they affect your health care organization as we progress through 2025 and beyond?

On this episode, Epstein Becker Green attorneys Sarah Hall, Melissa Jampol, Thomas Jaworski, and Richard Westling discuss what to expect from criminal health care fraud enforcement under Attorney General Bondi’s leadership and how it may impact the health care industry.

How can you advocate for your needs and priorities in a time of such uncertainty? 

On this episode, Epstein Becker Green (EBG) attorneys James Boiani, Rachel Snyder Good, Marjorie Scher, and Rob Wanerman discuss the proposed leadership of the U.S. Department of Health and Human Services under the second Trump administration and the top-ticket items for these potential new leaders.

From policymakers to stakeholders across the industry, everyone is wondering what health policy will look like in 2025 and beyond.

On this episode, Epstein Becker Green attorneys Ted Kennedy Jr., Leslie Norwalk, Philo Hall, and Alexis Boaz discuss the results of the 2024 elections and their impact on the health policy space. What will a second Trump administration look like? How might the election results affect the health care policies addressed during Congress’s 2024 lame-duck session?

These notices follow the issuance of CMS’s final rule (88 Fed. Reg. 6643 (Feb. 1, 2023), amending 42 C.F.R. 422.310(e). Pursuant to the rule, CMS has the authority to extrapolate audit findings for PY2018 and beyond. CMS has noted that the extrapolation methodology it adopts for RADV audits will be focused on MAO contracts that, through statistical modeling ...