Medicare Advantage is undergoing a reckoning ... and that reckoning is coming from within.

In January Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that it violated the False Claims Act by submitting invalid diagnosis codes for their MA Plan enrollees in order to receive higher payments from the government.

The case was instigated by what is known as whistleblowers.

Regular listeners might recall my podcast on this topic back in January 2025 with Mary Inman, a Partner at Whistleblower Partners LLP, and Head of International Whistleblower Practice for the firm. We had a fascinating conversation about the process of whistleblowing and New York insurer Independent Health, which agreed in December 2024 to pay $100M to settle allegations it had upcoded claims to inflate MA payment.

We’ve now more than 5x-ed that fine with Kaiser. Per the Department of Justice the claims resolved by the settlement are allegations only and there has been no determination of liability. But it was a major wakeup call for MA.

Mary is back for today’s show along with her colleague Liz Soltan, a senior associate in the firm’s NYC office. Listen in as we discuss:

Key terms: What is whistleblowing and the concept of qui-tam?

Kaiser case origins which began more than 12 years ago, and Mary and Liz’s evolving roles in the case

The facts on the ground, as alleged by the whistleblowers and the DOJ, specifically the issue of addenda to the medical record

Unfolding of the case, a behind the scenes look as new whistleblowers joined, and reaching of the settlement

What can we learn from a medical coding/reimbursement perspective?

What can healthcare organizations do to ensure their employees don’t blow the whistle and avoid similar fines and headlines?