Before The FCA: CMS And HHS Leaders Discuss Administrative Tools Leading Healthcare Fraud Enforcement

Last week, federal healthcare fraud leaders came to the American Health Law Association’s (AHLA) Fraud and Compliance Forum in Washington, D.C. with a clear message: enforcement increasingly starts at the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). Brenna Jenny, Deputy Assistant Attorney General for the Commercial Litigation Branch of the U.S. Department of Justice’s (DOJ) Civil Division, moderated a fireside chat with the following participants: Kim Brandt, Deputy Administrator and Chief Operating Officer, CMS; Susan Gillin, Assistant Inspector General for Legal Affairs, HHS-OIG; and Beth Kelley, Acting Deputy General Counsel, HHS Office of the General Counsel (OGC).

At AHLA’s Annual Meeting in June 2026, the theme was partnership. This time, the panel showed its work. Here’s what you need to know.

Administrative Sanctions

Brandt walked through CMS’ six-month nationwide enrollment moratoria. The moratorium on certain durable medical equipment (DME) suppliers ran from February 2026 until late August 2026. The moratoria on hospice and home health agencies (HHAs), in effect since May 13, 2026, runs through mid-November 2026. The logic behind these moratoria is that wrongdoers shut out of one provider type tend to resurface in another, so CMS applied pressure to several at once.

As a result, CMS saw billing shift into Medicare Advantage (Part C). Brandt said that CMS responded with administrative action: the preclusion list, revocations, and suspensions. OIG’s data analytics helped spot the shift. Gillin said her team meets to validate data and choose remedies, and has leveraged its powerful exclusion remedies to prevent wrongdoers’ participation in all federal healthcare programs.

The pressure extends beyond Medicare:

• Medicaid. CMS’ “Medicaid War Room” targets personal care services, autism services, and adult day care. (See our coverage of HHS’ Medicaid payment deferrals.) Brandt noted that regional roundtables involved 46 states to help partner with states on Medicaid fraud enforcement.
• The ACA exchanges. Last week, CMS paused registration of new agents and brokers who help consumers enroll in ACA Marketplace coverage through HealthCare.gov. Agents and brokers without a 2026 agreement with CMS cannot register to assist consumers for plan year 2027 until February 1, 2027.

Staying Out of CRUSH’s Crosshairs

Brandt reported that in 2026, CMS revoked or suspended almost 1,600 providers and suppliers and denied roughly 110,000 fee-for-service claims after medical record review. To avoid becoming a target of CMS’ Comprehensive Regulations To Uncover Suspicious Healthcare (CRUSH) anti-fraud initiative, the panel advised:

• Know your medical directors. CMS is using its affiliation authority, so hospices and HHAs should vet their medical directors’ backgrounds and affiliations.
• Document everything, including support for live discharge rates. If you didn’t document it, you didn’t do it.
• Execute corrective action plans fully and on time.

CMS also is using the U.S. Department of the Treasury’s financial crimes data — this is how CMS connected one bank account to more than 300 California hospices with no other evidence of affiliation.

OIG’s Guidance Pipeline

The panel addressed certain developments in OIG compliance guidance, including:

• Advisory opinions after Vertex. Gillin addressed the D.C. Circuit’s September 4, 2026 decision in Vertex Pharmaceuticals v. HHS. There, the court affirmed OIG’s anti-kickback analysis; however, it remanded the case for further development on the Beneficiary Inducement Statute. The court held that OIG’s timing regulations improperly evade the statutory deadline for advisory opinions.
  Gillin noted that OIG cannot toll the deadline and is weighing how to comply, since requests for additional information and required consultations with DOJ and OGC still add time to the advisory opinion process. Her advice: if you have a pending request, contact your OIG attorney.
• New compliance guidance. The next Industry Segment-Specific Compliance Program Guidance (ICPG), covering laboratories, is coming soon. Hospitals, pharmaceutical manufacturers, and hospices will follow. These build on the Medicare Advantage ICPG released in February.
• CIA as roadmaps for compliance best practices. As we reported earlier this year, OIG revised its model Corporate Integrity Agreement (CIA) obligations. Gillin highlighted the Veloxis Pharmaceuticals, Inc. CIA as an example of best practices providers can use to monitor for compliance risks.

DOJ Revisits the Justice Manual

Kelley and Jenny closed with DOJ’s September 18, 2026 Justice Manual revisions, which make two changes:

• Sub-regulatory guidance. DOJ reinstated its 2017 policy that sub-regulatory guidance cannot impose legal obligations beyond statute or regulation. The panel said this brings clarity to a gray area.
• Qui tam dismissals. DOJ now will assess in every declined qui tam whether to seek dismissal under 31 U.S.C. § 3730(c)(2)(A).

The panel stated that dismissals preserve limited resources, because CMS spends significant time on declined cases that relators continue to pursue. The review also sharpens DOJ’s early read on a case’s strengths and weaknesses.

What This Means for Providers

Coordination between DOJ and HHS is incredibly close. Moratoria, revocations, exclusions, and claim denials are increasingly the first line of enforcement, well before any False Claims Act case. Compliance fundamentals matter more than ever, and so does knowing whom to call when the government gets it wrong.