A quick bit of background
Two federal agencies police healthcare fraud. The Justice Department (DOJ) handles criminal cases. The HHS Office of Inspector General (OIG) is the health department's internal watchdog and handles civil and administrative penalties.
Justice Department. Handles criminal cases.
Health department's internal watchdog. Handles civil and administrative penalties.
For years, a practice that found a problem and wanted to come forward had to guess which agency to tell, or tell both. Coming forward on your own usually earns lighter treatment than getting caught.
What's changing
Under a new joint policy announced in mid-October 2026:
- Possible criminal fraud should be reported to the DOJ.
- Reporting to the DOJ can still earn the practice the OIG's credit for coming forward.
- Reporting only to the OIG generally won't qualify the practice for the DOJ's main reward: a decision not to prosecute.
- The new policy doesn't cover civil cases under the False Claims Act, the law used in most billing fraud lawsuits.
- ✓Can earn a decision not to prosecute
- ✓Can still earn the OIG's credit for coming forward
- ✕Generally won't qualify for a decision not to prosecute
One law firm called this a "one-way street." Pick the wrong door first and you may not be able to go back.
What it means for your practice
Most practices will never face this. Everyday billing mistakes, like a wrong code or an accidental double charge, are still fixed the normal way: you refund the insurer or Medicare. This change only matters for problems serious enough that someone might have broken the law on purpose, such as kickbacks or fake claims.
What to do now
Want to catch billing problems early?
A regular billing audit finds wrong codes and overpayments while they are still simple refunds.