In recent weeks, the U.S. Department of Justice (DOJ) has announced three settlements of False Claims Act (FCA) matters—including a $541.5 million settlement just last week— against healthcare providers partnering with Medicare Advantage plans for allegedly causing the submission of false diagnosis codes. In two of the settlements, the settling parties received credit for self-disclosure and cooperation with DOJ. These settlements underscore DOJ’s focus on fraud by healthcare providers and risk-sharing payment arrangements in the Medicare Advantage program, as well as the potential benefits to enforcement targets of self-disclosure and cooperation.
Background
Medicare Advantage, also known as Medicare Part C, gives seniors the option to receive Medicare benefits by enrolling in private healthcare plans. The Centers for Medicare & Medicaid Services (CMS), which oversees the Medicare program, pays Medicare Advantage plans a fixed amount each month for each enrolled senior. CMS then adjusts that amount to account for the health status and demographic characteristics of a given plan’s enrolled population—a process known as “risk adjustment.” For enrollees with more severe health conditions based on the diagnosis codes reported by...
Compliance It’s the second federal contractor to settle with the Department of Justice over claims related to DEI programs without admitting to any wrongdoing. August 31, 2026 • 3 min read I-9 in n...