On January 14, 2026, the Department of Justice announced that five Kaiser Permanente affiliates had agreed to pay $556 million to resolve False Claims Act allegations that they submitted unsupported diagnosis codes for Medicare Advantage enrollees to inflate reimbursements from the federal government. The settlement is the largest False Claims Act resolution involving Medicare Advantage risk adjustment fraud in history. Whistleblowers who brought the case received a share of the recovery. The … [Read more...]
Sutter Health Medicare Advantage Fraud Case Shows the Power of Whistleblowers
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...]
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Procurement Fraud Whistleblowers May Have Two Paths to Recovery The Department of Justice is sending a clear message to the market: if you have knowledge of anticompetitive conduct affecting federal procurement, the government wants to hear from you. A recent keynote address by Acting Deputy Assistant Attorney General Daniel Glad made plain that criminal antitrust enforcement is accelerating and that whistleblowers are now central to that effort. For individuals with knowledge of bid … [Read more...]
Why Whistleblowers Should Not Use AI to Draft Case Summaries
Why Whistleblowers Should Not Use AI to Draft Case Summaries If you believe your employer has been defrauding the federal government, your first instinct may be to organize your thoughts before contacting an attorney. Increasingly, potential clients are turning to AI tools like ChatGPT to help draft case summaries or intake narratives before reaching out to a law firm. While that impulse is understandable, using AI to build your case summary can create serious legal risks that may compromise … [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...]
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