Six whistleblower lawsuits allege that doctors in the Kaiser Permanente network were pressured into submitting diagnostic codes for more severe or additional diagnoses than patients actually had.
The Department of Justice announced last week that it would be intervening on behalf of six False Claims Act lawsuits filed against Kaiser Permanente. The lawsuits allege that Kaiser and its affiliates submitted inaccurate diagnostic codes in order to reap greater reimbursements from Medicare Advantage enrollees.
"Medicare's managed care program relies on the accuracy of information submitted by health care providers and plans to ensure that patients receive the appropriate level of care, and that plans receive the appropriate compensation," said Deputy Assistant Attorney General Sarah E. Harrington of the Justice Department's Civil Division. "Today's action sends a clear message that we will hold health care providers and plans accountable if they seek to game the system by submitting false information."
Recommended For You
Since 2013, six whistleblower lawsuits have been filed alleging that doctors in the Kaiser Permanente network were pressured into submitting diagnostic codes for more severe or additional diagnoses than patients actually had, which would increase their CMS risk score and result in higher reimbursements–as much as $3,000 per patient, by one estimate. These changes were made months or years after the initial patient visit, the lawsuits allege.
"We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements and we intend to strongly defend against the lawsuits alleging otherwise," Kaiser said in a statement. "Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS."
The cases will be heard in a California federal court.
© 2025 ALM Global, LLC, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to [email protected]. For more information visit Asset & Logo Licensing.
Emily Payne
Emily Payne is director, content analytics for ALM's Business & Finance Markets and former managing editor for BenefitsPRO. A Wisconsin native, she has spent the past decade writing and editing for various athletic and fitness publications. She holds an English degree and Business certificate from the University of Wisconsin.
