The 2026 fraud takedown shows how long schemes bill before they stop. On June 23, the Justice Department announced charges against 455 defendants in schemes involving more than $6.5 billion in false claims, the most defendants in the history of its annual National Health Care Fraud Takedown. The largest case was in wound care. It involved more than $4 billion billed to Medicare and more than $2 billion paid. It ran from about December 2021 through June 2024, according to DOJ.
That last detail matters more than the headline total. A takedown measures what prosecutors charged. It does not measure how long the money flowed before anyone stopped it, and that interval is the part payers control. Payers and regulators should report the lag between the first signal of a scheme and the moment payments stop, and treat shortening it as the goal.
Key takeaways
- The takedown set a record for defendants. DOJ charged 455 people, including 90 doctors and other licensed professionals, across 56 federal districts.
- Medicaid cases led the count. DOJ charged 295 defendants in Medicaid schemes involving more than $518 million, the largest Medicaid action in its history.
- Wound care led the dollars. In the Arizona allograft case, providers billed Medicare more than $4 billion and were paid more than $2 billion.
- Administrative actions reached further. CMS suspended 1,079 providers and revoked billing privileges for 1,403. HHS-OIG excluded more than 1,400.
- Totals are not a trend line. The 2025 takedown alleged $14.6 billion, most of it from a single case. Year-to-year comparisons measure enforcement choices more than fraud.
- The lag is the measure that matters. The time from the first visible signal to the payment stop decides how much is lost. Payers should measure and report it.
What the 2026 takedown found
DOJ’s announcement described the effort as its largest yet by defendants. All 50 state Medicaid Fraud Control Units took part, the most in the department’s history.
| Measure | 2026 takedown |
|---|---|
| Defendants charged | 455 |
| Doctors and other licensed professionals | 90 |
| Federal districts | 56 |
| Alleged false claims | More than $6.5 billion |
| Providers suspended by CMS | 1,079 |
| Billing privileges revoked by CMS | 1,403 |
| Providers excluded by HHS-OIG | More than 1,400 |
| Assets seized | More than $182 million |
From the DOJ release (June 2026) and Arnold & Porter (June 2026).
The release also describes 25 civil monetary penalty actions by HHS-OIG seeking more than $10 billion, tied to payments CMS suspended before they were made. The Drug Enforcement Administration opened 928 administrative cases to revoke authority to handle controlled substances. HHS-OIG’s own summary credited its investigations with charges against 111 defendants and more than $6.1 billion in intended losses.
The professional defendants deserve a note of their own. DOJ counted 90 doctors and other licensed professionals among those charged, and HHS-OIG excluded more than 1,400 providers from federal health programs. Every exclusion is also a credentialing event. Health plans must stop paying excluded providers, which makes the exclusion list one of the fastest signals a plan can act on. Our case that credentialing should be a feed applies here, because a plan that checks exclusions monthly can pay an excluded provider for weeks.
Wound care
Wound care produced the largest case. DOJ charged 11 defendants across 6 districts in schemes involving amniotic allografts, a type of skin substitute. In Arizona, providers billed Medicare more than $4 billion for a single company’s allografts, which led to more than $2 billion in payments. A vice president of sales allegedly received more than $24 million. Separate cases involved a $906 million scheme charged against a Texas nurse practitioner and a $118 million scheme in Florida.
The pattern was not hidden. HHS-OIG warned in a September 2025 report that Part B payment trends for skin substitutes raised major concerns. CMS reported in October 2025 that Medicare spending on skin substitutes rose from about $256 million in 2019 to more than $10 billion in 2024, and it cut payment for the products by nearly 90% for 2026. Our analysis of skin substitute spending traced that curve. DOJ said its own data analytics team detected a spike in allograft payments that led to prosecutions.
Medicaid
Medicaid accounted for most of the defendants. DOJ charged 295 people in schemes involving more than $518 million in false claims submitted to Medicaid. The average Medicaid case was far smaller than the wound care cases, which reflects how Medicaid fraud tends to work. It is spread across state programs and managed care plans, and many schemes involve personal care or behavioral health services billed in smaller amounts.
Medicaid already collects some of the signals that matter. Under the 21st Century Cures Act, states must use electronic visit verification for Medicaid personal care services. The system records when and where each visit took place. A visit that the verification data does not support is a lead that can be checked quickly.
Managed care adds a layer. Most Medicaid enrollees are in managed care plans, which run their own program integrity units and pay their own claims. A scheme that bills several plans in the same state can look small to each of them.
An Illinois behavioral health case involving $67 million was the first prosecution from DOJ’s Financial Intelligence Review Team, according to Arnold & Porter.
Transnational schemes
Several cases reached across borders. DOJ described a transnational criminal organization responsible for billions in fraudulent durable medical equipment claims, with a defendant arrested in Kyrenia in a case involving an additional $3.7 billion. DOJ also secured the extradition of 2 defendants from Estonia. A fugitive in a $1.2 billion telemedicine scheme was apprehended in the Philippines.
Other cases included an $89 million scheme involving unnecessary cardiac testing of student athletes and an operation that dispensed Schedule II prescriptions without patient interaction.
How the schemes were found
Analytics drove many of the cases. DOJ’s Health Care Fraud Data Fusion Center, announced as part of the 2025 takedown, “used advanced analytics in many of the cases charged today,” according to the release. In wound care, the Health Care Fraud Unit’s data analytics team detected the spike in allograft payments that led to prosecutions.
Other parts of the government contributed different signals. The Illinois behavioral health case was the first prosecution from DOJ’s Financial Intelligence Review Team, according to Arnold & Porter. DOJ also announced new data-sharing agreements with CMS and other federal agencies. All 50 state Medicaid Fraud Control Units took part, and their cases produced most of the defendants.
The common thread is that the signals existed in payment data before the charges. The wound care spike appeared in Medicare’s own spending. Medicaid schemes left patterns in state claims. What the takedown cannot show is how quickly those signals reached someone with the authority to stop payment, and that is the question that decides the loss.
What the headline numbers measure
The $6.5 billion figure is alleged false claims. It is what prosecutors say the defendants billed or intended to bill, not what payers paid. The Arizona case shows the difference. More than $4 billion was billed and more than $2 billion was paid. The first number describes the scheme’s ambition. The second describes the loss.
The totals also move with the cases that happen to be ready. The 2025 takedown charged 324 defendants in schemes with more than $14.6 billion in intended loss, according to GRIP. A single transnational case, Operation Gold Rush, accounted for $10.6 billion of it. CMS said in 2025 that it prevented more than $4.4 billion from being paid and suspended or revoked 205 providers.
| Measure | 2025 takedown | 2026 takedown |
|---|---|---|
| Defendants | 324 | 455 |
| Alleged or intended loss | More than $14.6 billion | More than $6.5 billion |
| Largest single case | $10.6 billion, durable medical equipment | More than $4 billion billed, wound care |
| CMS administrative actions | 205 providers suspended or revoked | 1,079 suspended, 1,403 revoked |
| Assets seized | More than $245 million | More than $182 million |
Compiled from press coverage of both takedowns and the DOJ release (June 2026). The years use different loss measures, so the dollar rows are not directly comparable.
Prevention beats recovery
The administrative numbers point to where the value lies. Assets seized across every 2026 case totaled more than $182 million. The Arizona allograft case alone produced more than $2 billion in payments. Recovery after the fact rarely comes close to what was paid. The $10 billion tied to payments CMS suspended before they went out is a different kind of number, because that money never left the trust fund.
A reader could conclude from the totals that fraud fell by more than half. That would be wrong. The 2025 total was dominated by a single case, and the 2026 count was dominated by Medicaid cases that are small in dollars. The administrative numbers moved the other way, with far more providers suspended or revoked in 2026. Takedowns are also snapshots. A case charged in June 2026 may have begun years earlier, and a scheme stopped in 2025 may not be charged until 2027. Takedown totals describe what enforcement chose to bring in a given year. They are not a measure of how much fraud exists, a point our review of health care waste made about improper payment rates too.
The lag between signal and stop
The number that decides the loss is time. A scheme that bills for a month loses a month of payments. A scheme that bills for years loses years of them. The Arizona allograft scheme ran from about December 2021 through June 2024, according to DOJ, while national spending on the products climbed in public data.
A takedown counts what was charged. The loss was decided earlier, by how long the payments kept going.
If a scheme is paid at a steady rate, every month cut from the lag is a month of payments saved. That arithmetic holds for a $5 million scheme and a $2 billion one.
Every large case has a timeline with 4 points. The scheme starts billing. A signal appears in the data, such as a spending spike or a provider billing far outside its peers. Someone acts on the signal and stops or slows payment. Prosecutors charge the case. The takedown reports the last point. The loss depends mostly on the distance between the second and the third.
| Stage | What happens | Who usually acts |
|---|---|---|
| Billing begins | Claims start flowing for the scheme | The provider |
| Signal appears | Spending or billing patterns depart from the norm | Payer analytics and investigators |
| Payment stops | Prepayment review or suspension | Payers and regulators |
| Charges filed | Indictment or complaint | DOJ and state units |
Our framework.
Report the lag
Payers and regulators could publish the lag for major cases. For each case, the report would give the date billing began and the date the first signal crossed a threshold. It would also give the date payments stopped and the amount paid in between. Over several years, the trend would show whether detection is getting faster, which no takedown total can show.
CMS already has the raw material. The 2026 actions included more than 1,000 suspensions and more than $10 billion in suspended payments now subject to penalty actions. A lag report would show how quickly those suspensions followed the first signal. Medicare Advantage plans and Medicaid managed care plans could report the same measure for their own programs, since they pay claims CMS never sees.
Measuring the lag honestly
The hard part is defining the first signal. Looking back, every scheme seems obvious, which is the hindsight problem our two-midnight analysis described in another setting. A fair measure uses thresholds set in advance. A service category that grows past a set rate, or a provider that bills past a set multiple of its peers, starts the clock. The lag is then the time from crossing the threshold to a decision, not from the moment an analyst later says the pattern was visible.
Shorten it without punishing the honest
A shorter lag is not the same as more stops. A payer that suspends every provider with an unusual pattern will stop fraud faster and will also stop care. Many unusual patterns have honest explanations, such as a new specialist joining a practice or a change in patient mix. Our piece on prepayment review as a diagnostic test argued that review should be measured like a test, with both its misses and its false alarms counted.
The goal is a faster path from signal to a human decision. A spending spike triggers a review within days, not quarters. A reviewer with clinical and billing expertise decides whether to stop payment or let it continue under closer review, with the reasons on record. Honest providers get a quick answer, and dishonest ones lose their head start.
Wound care is the clearest test. The spending curve was public. The question for the next scheme is whether the signal reaches a decision in weeks or in years.
What payers can do now
Most payers do not need new authority to shorten the lag. They need a faster path from analytics to a decision, and a way to measure it. Medicare Advantage plans and Medicaid managed care plans pay their own claims, so the lag in their programs is their own. A scheme that bills traditional Medicare and private plans at the same time can be stopped in one program and keep billing in another.
- Watch growth by service, not only by provider. The allograft spike was visible at the level of a product category before any single provider stood out. A service whose spending doubles in a year deserves a look even when no individual biller looks extreme.
- Weigh newness. Schemes often run through new or recently acquired billing entities. A new biller with rapid volume growth is a stronger signal than an established practice with the same volume.
- Set a review clock. Decide in advance how many days a high-priority signal may wait before a reviewer decides what to do. Then measure against that clock every month.
- Share signals across payers. CMS runs the Healthcare Fraud Prevention Partnership, which lets public and private payers share information about schemes. A signal shared there can shorten the lag for every payer that receives it.
- Report the lag. For the year’s largest cases, report the time from first signal to decision and the amount paid in between. Report it to the board, and to regulators where they ask.
Payers should also be wary of judging their programs by recoveries alone. A large recovery can mean a scheme was caught. It can also mean the scheme ran for a long time before anyone noticed. A program that stops schemes early will report smaller recoveries, and it will have lost far less.
None of these steps requires a payer to stop more providers. They require it to decide faster, with a person accountable for the decision and the reasons written down.
Where Redlake stands
Redlake builds tools that health plans use in utilization review, and payment integrity work runs on the same principles. A machine can say yes, but only a person can say no. In fraud work, that means an analytic signal can open a review, but a person decides whether to stop payment to a provider. Every recommendation shows its reasons, so a provider whose payments are held can see why. Every decision can be reconstructed, so the timeline from signal to stop can be measured at all.
The same rules protect honest providers. A provider flagged by an analytic model should hear from a person and see the reasons. It should also have a chance to answer before a payment hold becomes a long one. Speed and fairness are not in tension when the decision is made by someone accountable and recorded where it can be checked.
We think the lag belongs in every payment integrity report. A plan that can say how long its signals take to reach a decision is a plan that can improve. A plan that reports only recoveries is reporting what it failed to prevent.
What to watch in the rest of 2026
- Data sharing. DOJ announced new data-sharing agreements with CMS and other agencies alongside the takedown. Watch whether they shorten the time from signal to action.
- Wound care after the payment cut. CMS’s 2026 payment changes for skin substitutes took effect in January. Watch whether spending falls as projected or shifts to other products and settings.
- Medicaid oversight. The record Medicaid caseload will test state program integrity units and managed care plans. Our coming analysis of Medicaid integrity will look at how states detect schemes that bill in small amounts.
- Prior authorization in traditional Medicare. The WISeR model began in 6 states in January 2026. Its list of reviewed services includes skin and tissue substitutes, as our WISeR analysis described. Watch whether it changes billing patterns in those states.
- Civil follow-on cases. Criminal takedowns are often followed by False Claims Act actions. Our review of FY2025 False Claims Act results covers that pipeline.
About this analysis
Method. The sources are DOJ’s June 2026 takedown announcement, HHS-OIG’s summary and law firm coverage. The 2026 results are compared with press coverage of the 2025 takedown and with CMS data on skin substitute spending.
Data notes. Takedown figures are as DOJ and HHS-OIG reported them. Alleged false claims and intended loss are not payments, and the 2025 and 2026 releases use different terms. The lag framework is this analysis’s proposal, not a measure CMS or DOJ publishes. Charges are allegations, and defendants are presumed innocent unless proven guilty.
Sources. DOJ, takedown announcement (June 2026). HHS-OIG, takedown summary (June 2026). Arnold & Porter (June 2026). GRIP (July 2025). HHS-OIG, skin substitute payment report (September 2025). CMS, physician fee schedule announcement on skin substitutes (October 2025).
Frequently asked questions
What was the 2026 National Health Care Fraud Takedown?
It was DOJ’s annual coordinated enforcement action, announced on June 23, 2026. It charged 455 defendants, including 90 licensed professionals, in schemes involving more than $6.5 billion in alleged false claims.
What was the largest case in the 2026 takedown?
An Arizona wound care case involving amniotic allografts. Providers billed Medicare more than $4 billion for a single company’s products, which led to more than $2 billion in payments.
Did health care fraud fall from 2025 to 2026?
The totals do not show that. The 2025 takedown’s $14.6 billion was dominated by a single $10.6 billion case. Takedown totals reflect which cases were ready to charge, not how much fraud exists.
What is the lag between signal and stop?
It is the time between the first visible sign of a scheme in payment data and the moment payments stop. The loss in a fraud case depends mostly on that interval. Payers and regulators should measure and report it for major cases.
What did CMS do as part of the takedown?
CMS suspended 1,079 providers and revoked billing privileges for 1,403. HHS-OIG brought penalty actions seeking more than $10 billion tied to payments CMS suspended before they were made.