In August 2021 Sutter Health agreed to pay $90 million to settle allegations that it submitted inaccurate diagnosis data to inflate Medicare Advantage payments. The case began with a whistleblower. This page explains how the fraud worked and what it means for people working in Medicare Advantage.Sutter Health Medicare Advantage Fraud Case Shows the Power of WhistleblowersIn August 2021, Sutter Health and several affiliated medical foundations agreed to pay $90 million to settle allegations … [Read more...]
Pharmaceutical Fraud: Off Label Marketing, Kickbacks, and False Claims Act Liability
Pharmaceutical companies have produced some of the largest False Claims Act settlements in history, driven by off label marketing and kickbacks to physicians. This page explains what conduct creates liability and how the False Claims Act protects the people who report it.Pharmaceutical Fraud: Off Label Marketing, Kickbacks, and False Claims Act LiabilityPharmaceutical companies have produced some of the largest False Claims Act settlements in history, and enforcement in this area continues … [Read more...]
Hospital Billing Fraud: Common Red Flags for Whistleblowers
Hospital Billing Fraud: Common Red Flags for WhistleblowersHospitals and health systems are among the most frequent targets of False Claims Act enforcement. The Department of Justice recovered over $5.7 billion in healthcare fraud settlements in fiscal year 2025 alone, the highest total ever recorded. A significant portion of that recovery came from cases involving hospitals, and many of those cases began with someone on the inside who noticed something wrong and came forward.If you work … [Read more...]
CMS Proposed Rule Targets Medicare Advantage Risk Adjustment Fraud
CMS Proposed Rule Targets Medicare Advantage Risk Adjustment FraudThe Centers for Medicare & Medicaid Services 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 proposedOn January 26, 2026, CMS released … [Read more...]
Prescription Drug 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, prescription drug 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 … [Read more...]