Whistleblower Partners is proud to announce that our client, Dr. James Taylor, the United States, and another whistleblower have reached a settlement with Kaiser Permanente and various subsidiaries to resolve allegations of Medicare Advantage risk adjustment fraud for $556 million. This is the largest False Claims Act settlement in over three years. It is also the largest FCA settlement ever under Medicare Advantage, as well as the largest settlement resolving allegations of risk adjustment fraud.
Medicare Advantage, also known as Medicare Part C, is a managed care alternate system to traditional Medicare. In Medicare Advantage, the government partners with private insurers and pays them a premium to cover Medicare beneficiaries. The premium payment is generally higher if the beneficiaries have more documented health conditions, which incentivizes making patients appear sicklier than they are. To combat this issue, Medicare sets specific rules for medical record documentation and sourcing. Kaiser Permanente and its subsidiaries are now resolving allegations that they flaunted those rules.
Dr. Taylor, a longtime Kaiser physician and former medical director responsible for coding governance, compliance, and revenue-cycle oversight, filed his whistleblower complaint after Kaiser failed to address practices he had identified that allegedly inflated beneficiaries’ risk scores and increased Medicare reimbursements without corresponding clinical justification. “Physicians are trained to document care truthfully and accurately,” said Dr. Taylor. “When financial pressure overrides that principle, it undermines trust in the system. I stayed as long as I did because I believed the problems could be fixed internally. There were moments of progress, but too often the solutions were undone. Filing a complaint was a last resort, not a first step. I’m grateful to Whistleblower Partners for standing with me and helping ensure these issues were taken seriously.”
“Dr. Taylor raised concerns internally long before he went to the government,” added Michael Ronickher, partner at Whistleblower Partners. “His persistence and commitment to justice are inspiring.”
Our client’s whistleblower complaint alleged Kaiser engaged in systemic and improper Medicare Advantage risk adjustment practices, including adding and retaining diagnosis codes not supported by patients’ medical records, leading to inflated Medicare reimbursements to Kaiser. “Working closely with Dr. Taylor over multiple years, we helped develop detailed, technically grounded allegations rooted in his firsthand experience inside Kaiser’s Medicare Advantage operations,” said Max Voldman, partner at Whistleblower Partners. “This settlement reflects the importance of whistleblowers who understand how these systems actually work.”
This settlement resolves two cases brought by Dr. Taylor and another whistleblower. The government joined in part of Dr. Taylor’s lawsuit and also in the other whistleblower’s lawsuit. “This settlement underscores that size and complexity are not shields from accountability,” said Hamsa Mahendranathan, partner at Whistleblower Partners. “Whistleblowers with firsthand expertise remain the most effective check when internal systems fail.”
Several Whistleblower Partners attorneys contributed to this matter over the last twelve years, including Mary Inman, Hamsa Mahendranathan, Hallie Noecker, Mike Ronickher, Liz Soltan, and Max Voldman, with critical contributions from paralegal Karen Yang. Many former colleagues also played significant roles in the case, as well as our co-counsel at Phillips & Cohen LLP. We are happy to share this important success with our current and former colleagues.
We are also deeply grateful to the substantial efforts of a large Government team over the years of the case, including Laurie Oberembt (who led the team), Braden Civins, Edward Crooke, Gary Dyal, Michael R. Fishman, Martha Glover, Seth W. Greene, Rachel Karpoff, Michelle Lo, Kevin Traskos, and their colleagues.
This is the sixth successful settlement in which Whistleblower Partners attorneys have represented whistleblowers alleging risk adjustment fraud. Whistleblower Partners attorneys continue to pursue similar charges against UnitedHealth Group, which is poised to be the largest intervened risk-adjustment case in history. We have significant experience representing qui tam relators in healthcare fraud cases. If you would like more information or would like to speak to an attorney at Whistleblower Partners, please contact us for a confidential consultation.
