The Centers for Medicare & Medicaid Services (CMS) recently announced a proposed rule that would restrict a widespread billing practice used by Medicare Advantage plans to inflate payments from the federal government. The proposal signals that the government is committed to combating risk adjustment fraud, an area with substantial and growing False Claims Act exposure. What CMS Proposed On January 26, 2026, CMS released its 2027 Advance Notice, which included a proposal to exclude patient … [Read more...]
Prescription drug price fraud persists; whistleblowers help root it out
The federal government has been working to make pricey prescription drugs more affordable for the roughly 54.1 million people who are enrolled in the Medicare prescription program, known as Part D. However, fraud threatens to cost both the government and individuals suffering from health conditions significant amounts of money. Whistleblowers — working people who witness wrongdoing and courageously report it — can play a key role in protecting both. The government has been pursuing drug … [Read more...]
Report Says Medicare Part C Insurers Are Pocketing Billions Through Risk Adjustment Schemes
Medicare Advantage, or Part C, was created with the idea that private insurers could provide more cost-effective healthcare than traditional Medicare. But while the program has become popular — it’s the largest taxpayer-funded health insurance program in the United States with a $450 billion annual budget and more than 31 million participants — it is losing billions to fraud. As recent False Claims Act settlements and a recent report in the Wall Street Journal show, one of the costliest … [Read more...]
Sutter Health settlement part of record year for whistleblower recoveries
A record $90 million False Claims Act settlement for the government as a result of a whistleblower lawsuit by a Keller Grover client was among the cases highlighted by the U.S. Department of Justice in a recent announcement touting its 2021 recoveries under the Act. On Feb. 1, Acting Assistant Attorney General Brian M. Boynton announced DOJ had recovered more than $5.6 billion from False Claims Act settlements and judgments in the 2021 fiscal year, the largest amount since 2014 and the … [Read more...]
Telemedicine fraud remains DOJ priority
As telemedicine fraud remains a top enforcement priority of the U.S. Department of Justice, whistleblowers can play a key role in helping the government recoup taxpayer dollars lost to fraud. In September 2021, the DOJ announced charges against more than 43 individuals in 11 judicial districts. The government alleged those individuals took part in schemes involving telemedicine leading to more than $1.1 billion in allegedly false and fraudulent claims being submitted to Medicare and other … [Read more...]