Healthcare Compliance in 2025: What Recent DOJ Actions Mean for Your Organization

Healthcare Compliance in 2025: What Recent DOJ Actions Mean for Your Organization

The Department of Justice’s recent record-breaking healthcare fraud enforcement actions – $14.6 billion across 324 cases – underscore what we’ve been telling clients all year: compliance isn’t optional anymore.

With the reestablishment of the DOJ-HHS False Claims Act Working Group and vastly expanded audit capabilities, federal agencies have moved from reactive enforcement to proactive surveillance. The message is clear: get your compliance house in order.

Key Areas of Heightened Focus:

• Medicare Advantage Oversight: CMS has announced plans to audit all 550+ Medicare Advantage plans annually, expanding from the previous 60 plans per year. This represents a fundamental shift in oversight strategy.
• Technology-Driven Surveillance: Government agencies are using advanced data analytics to identify billing outliers automatically, no whistleblower required.
• Expanded Scope: Enforcement now targets telemedicine compliance, durable medical equipment billing, EHR documentation integrity, network adequacy, essentially every revenue touchpoint.

The Smart Move: Proactive Partnership

Organizations waiting for enforcement actions to prompt compliance reviews are already behind. Smart healthcare leaders are strengthening their defenses now.

At Sage Clinical RCM, we work alongside healthcare organizations to strengthen their compliance infrastructure before issues arise. Our comprehensive approach includes:

✓ Clinical Documentation Improvement: Making sure your charts tell the right story accurately.
✓ Revenue Cycle Auditing: Finding issues before external auditors do.
✓ Denials Management: Turning rejections into recoveries while staying compliant.
✓ Staff Education & Training: Keeping teams sharp on evolving regulations.
✓ Compliance Program Development: Building frameworks that actually work.

We don’t just identify problems, we fix them. And we make sure they stay fixed.

Plus, we provide the technology backbone that makes it all sustainable. Our Sage IQ management software gives leadership real-time visibility into documentation quality, coding accuracy, and potential risk areas, which is the same kind of data analytics the government is now using to identify targets.

We don’t just identify problems, we fix them. And we give you the tools to prevent them from recurring.

The goal isn’t just compliance, it’s confidence. Confidence that when your name comes up in government data analytics, you’re ready.

Is your organization prepared for the new enforcement reality? Let’s talk about how we can help you stay ahead of it.