Sutter Health Medicare Advantage Fraud Case Shows the Power of Whistleblowers In August 2021, Sutter Health and several affiliated medical foundations agreed to pay $90 million to settle allegations that they submitted inaccurate diagnosis data to inflate payments under the Medicare Advantage program. The case is one of the largest Medicare Advantage fraud settlements on record, and it began with a single whistleblower, a former employee of the Palo Alto Medical Foundation who recognized what … [Read more...]
Pharmaceutical Fraud: Off Label Marketing, Kickbacks, and False Claims Act Liability
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, and enforcement in this area continues at a significant pace. The conduct at the center of these cases follows patterns that have repeated across the industry for decades: drugs promoted for uses the FDA has not approved, kickback payments disguised as speaker fees or consulting arrangements, and prescriptions … [Read more...]
Hospital Billing Fraud: Common Red Flags for Whistleblowers
Hospital Billing Fraud: Common Red Flags for Whistleblowers Hospitals 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 Fraud The 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 proposed On January 26, 2026, CMS released … [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...]