By Sara Mieczkowski
In its June 2025 National Health Care Fraud Takedown, the DOJ unveiled “Operation Gold Rush,” an alleged$10.6 billion fraud scheme involving durable medical equipment. What set that case apart was not only its scale, but how it was detected: through the DOJ’s own Health Care Fraud Unit’s Data Analytics Team, which flagged anomalous billing patterns before $4.4 billion in payments were made. The DOJ is now building a Health Care Fraud Data Fusion Center, a new hub that will combine AI and cloud computing to identify fraud faster and more precisely.
This strategy is not limited to healthcare. Deputy Attorney General Lisa Monaco has confirmed that the DOJ is using AI to triage over one million annual FBI tips, trace narcotics sources, and synthesize vast case evidence. Meanwhile, agencies like the DEA are already leveraging machine learning to pinpoint the geographic origins of seized drugs.
Still, a December 2024 DOJ Office of the Inspector General (OIG) report suggests that full-scale AI deployment remains aspirational. Funding, data quality, and infrastructure remain real hurdles for agencies like the FBI and DEA. But this gap will not last.
Entities wishing to avoid Government scrutiny are well advised to shore up their AI governance –policies, procedures, and oversight mechanisms that ensure artificial intelligence systems used in medical care are ethical, safe, transparent, and compliant with laws and regulations. It involves managing risks, protecting patient privacy, ensuring accurate billing and improving care while minimizing potential harms.
AI as a Source of Government Scrutiny
While the DOJ is building its AI enforcement arsenal, it is also targeting the misuse — and even the design — of AI by corporate actors.
In the same 2025 takedown, defendants in an alleged $703 million fraud scheme were charged with using AI-generated audio to impersonate patient consent. The DOJ has made clear it will seek sentencing enhancements when AI is used to “perpetrate” or “aggravate” criminal conduct.
Even lawfully deployed AI is under scrutiny. Since January 2024, the DOJ has issued subpoenas to digital health and pharmaceutical companies demanding information about algorithms used to synthesize patient data and recommend treatments. Investigators are probing whether these tools nudge physicians toward certain products, resulting in overbilling and possibly violating the False Claims Act.
This emerging line of inquiry presents a profound challenge. DOJ is not just asking whether AI works — it is asking whether the AI is biased, misleading, or designed to serve commercial goals over clinical ones. Companies are now expected to explain how opaque, often proprietary algorithms make decisions. “AI governance” is no longer a tech buzzword — it is a compliance imperative that requires interdisciplinary collaboration between legal, data science, and compliance professionals.
DOJ’s Updated Compliance: AI Governance Now Mandatory
On September 23, 2024, the DOJ revised its Evaluation of Corporate Compliance Programs (ECCP) to include AI-specific risk management criteria. This new guidance directs prosecutors to assess:
– How a company evaluates and mitigates AI-related risks;
– Whether AI oversight is embedded within broader enterprise risk frameworks;
– What controls exist to ensure lawful, reliable AI outputs;
– How human judgment is used to validate AI decisions;
– How AI accountability is tracked internally;
– And whether employees are trained on responsible AI use.
These questions are not abstract. They will shape declination decisions in False Claims Act investigations, cooperation credit, and potential penalties. Companies deploying AI in regulated industries such as Health Care, finance and Government procurement, must not only use AI responsibly but develop an “audit trail” of its AI functions.
Whistleblowers as Force Multipliers: A New Race to Disclose
Parallel to its tech evolution, the DOJ is aggressively expanding its whistleblower infrastructure, adding financial incentives and creating new reporting channels that incentivize employees to bypass internal processes and go straight to the government.
Criminal Division Expansion
In May 2025, the DOJ expanded its Corporate Whistleblower Awards Pilot Program, first launched in August 2024. The broadened scope now covers high-impact areas like:
– Customs and trade fraud;
– Immigration law violations;
– Sanctions evasion and money laundering.
Of note, this includes visa fraud — an area where traditional False Claims Act suits often flounder due to statutory limitations. Now, whistleblowers can report such schemes directly and still receive financial rewards.
Antitrust Division Joins the Fray
On July 8, 2025, the Antitrust Division launched its first-ever whistleblower rewards program in partnership with the U.S. Postal Service. Tipsters can now receive 15–30% of fines exceeding $1 million for reporting bid-rigging or price-fixing schemes that “affect the Postal Service.” While seemingly narrow, the DOJ may interpret this nexus broadly — for example, viewing e-commerce conspiracies as harming USPS revenue by reducing shipments.
Implications for Defense Counsel and Compliance Officers
For in-house counsel, compliance leaders, and defense attorneys, consider the following takeaways:
1. Audit your AI tools now
2. Embed AI governance into your EHR
3. Prepare for disclosure of the internal workings of your AI — create audit trail
4. Improve internal procedures for appropriate protection of employees disclosing wrongdoing.
Conclusion
DOJ’s dual approach of harnessing advanced technologies while demanding their responsible corporate use represents a significant compliance challenge. But it also offers a roadmap. Companies that build robust AI governance, respond swiftly to internal red flags, and treat whistleblowers seriously will be better positioned in this new era of high-tech enforcement.
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