We authored an article for Law360 outlining a recent Department of Justice (DOJ) intervention in a False Claims Act (FCA) customs fraud matter. Continue Reading DOJ’s Latest False Claims Act Customs Fraud Intervention
DOJ Settlement Highlights Customs, FCA Risks for Importers
On March 25, 2025, the U.S. Department of Justice (DOJ) announced an $8.1 million settlement in a civil case under the False Claims Act (FCA) related to alleged customs evasion by a California importer of wood flooring. The private whistleblower who reported the conduct received over $1.2 million in the matter. As we suggested in
Seoul Medical Group and Renaissance Imaging Medical Associates Settle Medicare Risk Adjustment Fraud Case for $62 Million
The Department of Justice announced this week that California-based primary care provider Seoul Medical Group, Inc. (SMG), SMG’s former president and majority owner, and California-based radiology group Renaissance Imaging Medical Associates Inc. (Renaissance) will pay a combined $62.85 million to resolve allegations of False Claims Act violations related to the submission of unsupported diagnosis codes to Medicare Advantage Organizations in order to increase reimbursement from the government.Continue Reading Seoul Medical Group and Renaissance Imaging Medical Associates Settle Medicare Risk Adjustment Fraud Case for $62 Million
The California Insurance Frauds Prevention Act: Recent Developments Regarding California’s Powerful Commercial Health Insurance Fraud Statute
We have previously discussed the California Insurance Frauds Prevention Act (IFPA)–a state antifraud statute that, while modeled on the False Claims Act (FCA), is unique in targeting fraud in the commercial health insurance space.Continue Reading The California Insurance Frauds Prevention Act: Recent Developments Regarding California’s Powerful Commercial Health Insurance Fraud Statute
Martin’s Point Health Care Inc.’s $22.4M Settlement Illustrates DOJ’s Focus on Part C Fraud
Last week, the U.S. Department of Justice (DOJ) announced a $22.4 million settlement resolving allegations that Martin’s Point Health Care, Inc. (Martin’s Point) violated the False Claims Act (FCA) by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees. Continue Reading Martin’s Point Health Care Inc.’s $22.4M Settlement Illustrates DOJ’s Focus on Part C Fraud
DOJ Focus on Medicare Advantage Insurers and FCA Liability
In a recent article for AIS Health – RADAR on Medicare Advantage, I discussed the Department of Justice’s (DOJ) focus on pursuing Medicare Advantage (MA) insurers for wrongdoing under the False Claims Act (FCA) related to recoupment of overpayments.Continue Reading DOJ Focus on Medicare Advantage Insurers and FCA Liability
CMS Proposed Rule Addresses Multiple Aspects of Medicare Advantage Program for 2024, Including an Overpayment Rule Update
On December 14, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that contemplates several changes to, and clarifications of, guidance for the Medicare Advantage (MA) program in coverage year 2024.
Judge Chen’s Message to Medicare Advantage Providers: ICD Guidelines Aren’t Suggestions
On November 14, Judge Edward Chen in the Northern District of California issued rulings on the pending motions to dismiss in U.S. ex rel. Osnek v. Kaiser Permanente, granting in part and denying in part Kaiser’s motion to dismiss.
Continue Reading Judge Chen’s Message to Medicare Advantage Providers: ICD Guidelines Aren’t Suggestions
SDNY Ruling in Anthem Sends a Signal to Medicare Advantage Litigants
In a decision issued on September 30, Judge Andrew Carter of the U.S. District Court for the Southern District of New York denied Anthem Inc.’s motion to dismiss a government lawsuit filed in March 2020 claiming Anthem submitted inaccurate diagnosis data in conjunction with its Medicare Part C plans that resulted in alleged overpayments in violation of the False Claims Act (FCA).
Continue Reading SDNY Ruling in Anthem Sends a Signal to Medicare Advantage Litigants
Medicare Advantage Plan Highlights Distinction for FCA Purposes between Clinically Inaccurate Diagnoses and Clinically Accurate Diagnoses that Allegedly Violate Subregulatory Guidelines
In a September 2022 filing in U.S. ex rel. Osinek v. Kaiser Permanente, the Kaiser Permanente consortium defendants (Kaiser) highlighted the distinction between clinically inaccurate diagnoses (factual falsity) and clinically accurate but incorrectly coded diagnoses (legal falsity) and its relevance in False Claims Act (FCA) actions.
Continue Reading Medicare Advantage Plan Highlights Distinction for FCA Purposes between Clinically Inaccurate Diagnoses and Clinically Accurate Diagnoses that Allegedly Violate Subregulatory Guidelines