DOJ Streamlines Health Care Fraud Self-Disclosure as Enforcement Priorities Expand

Key Takeaways

• The US Department of Justice (DOJ) provides a single disclosure pathway for potentially criminal health care misconduct to obtain benefits under both agencies’ programs.¹
• Corporate enforcement priorities emphasize management involvement, concealment, duration, and financial harm.²
• Lowenstein recommends reviewing reporting, escalation, remediation, and disclosure procedures as enforcement becomes more centralized.³

The DOJ and Department of Health and Human Services Office of Inspector General (HHS-OIG) announced on October 15, 2026, a policy establishing a single reporting pathway for companies voluntarily disclosing potential criminal health care misconduct. Qualifying disclosures to DOJ’s National Fraud Enforcement Division can receive benefits under both agencies’ disclosure programs.¹

The announcement follows an October 1 directive prioritizing health care fraud and formalizing coordination of corporate investigations. Together, these developments address how companies report misconduct and how prosecutors evaluate corporate cases.^2,3

What Changes Under the Self-Disclosure Policy?

Companies voluntarily reporting criminal conduct affecting a federal health care program to the Fraud Division’s Health Care Fraud Section will receive HHS-OIG Self-Disclosure Protocol benefits without a separate submission through the OIG portal.¹

The policy addresses overlapping enforcement exposure: an illegal kickback arrangement or billing scheme may trigger criminal, civil, and administrative consequences. HHS-OIG also updated its protocol to clarify that criminal conduct should be reported to DOJ.¹

Does Reporting to HHS-OIG Provide the Same DOJ Benefits?

DOJ stated that disclosure only to HHS-OIG generally will not constitute voluntary self-disclosure to the department or qualify a company for a declination on that basis. Companies seeking both programs’ benefits should report potentially criminal conduct to the Fraud Division first.¹

How Will DOJ Evaluate Corporate Fraud?

According to Sidley’s analysis, the October 1 directive prioritizes health care industry misconduct, including health care fraud, controlled substance distribution, and Food, Drug, and Cosmetic Act violations.²

Prosecutors must give substantial weight to factors including management involvement, concealment, and harm to taxpayer-funded programs. Listed thresholds include conduct lasting at least 3 years, affecting at least 3 federal districts, or causing financial harm to at least 25 victims or losses of at least $25 million. The factors are nonexhaustive.²

The directive retains DOJ’s existing Corporate Enforcement and Voluntary Self-Disclosure Policy, rather than replacing its standards.²

What Does This Mean for Managed Care Stakeholders?

National law firm Lowenstein Sandler’s analysis recommends that companies in priority sectors review compliance programs, internal reporting procedures, and escalation protocols. For managed care stakeholders evaluating these developments, those recommendations focus attention on how potential misconduct reaches compliance and legal teams and how disclosure decisions are assessed.³

The analysis also describes a more centralized enforcement structure. The Corporate Enforcement Section will participate throughout Fraud Division corporate investigations and assume primary responsibility for assessing compliance with corporate resolutions.³

For payers and managed care organizations, these developments highlight the ongoing importance of compliance oversight and timely responses to potential fraud.

References

1. US Department of Justice. National Fraud Enforcement Division and the Department of Health and Human Services announce self-disclosure protocol for criminal health care fraud. Published October 15, 2026. Accessed October 16, 2026. https://www.justice.gov/opa/pr/national-fraud-enforcement-division-and-department-health-and-human-services-announce-self
2. Sidley Austin. DOJ’s National Fraud Enforcement Division issues first corporate enforcement priorities. Published October 2, 2026. Accessed October 16, 2026. https://whitecollarwatch.sidley.com/2026/10/02/dojs-national-fraud-enforcement-division-issues-first-corporate-enforcement-priorities/
3. Algor JE, Gould JS, Maimin R, McBride SB, Jameson JB. DOJ’s Fraud Division sharpens corporate fraud focus: new priorities, centralized oversight, and data-driven investigations. Lowenstein Sandler. Published October 8, 2026. Accessed October 16, 2026. https://www.lowenstein.com/news-insights/publications/client-alerts/doj-s-fraud-division-sharpens-corporate-fraud-focus-new-priorities-centralized-oversight-and-data-driven-investigations-wcd