New HHS OIG Report Highlights FCA as Tool to Address Medicare Advantage Fraud Risk

February 12, 2026
Hamsa Mahendranathan

Last week, the Office of the Inspector General for the Department of Health and Human Services (HHS OIG) issued new compliance program guidance for parties involved in Medicare Advantage, updating the prior guidance it issued over two decades ago. The report flags several high priority risk areas, described below, and repeatedly warns that these parties may be exposed to False Claims Act (FCA) liability for engaging in such risky practices.

HHS OIG’s Medicare Advantage Risk Areas

The report flags several priority risk areas that Medicare Advantage parties’ compliance programs should consider and address:

  • Failing to ensure adequate provider networks and accurate provider directories. Ensuring enrollees have access to care is a key tenet of the MA program. As proof that these practices have led to successful FCA settlements, our attorneys represented a successful whistleblower in a False Claims Act settlement resolving allegations that a MA plan expanded into new markets with an inadequate network of providers, misstating the providers and facilities available.
  • Implementing utilization management tools, like prior authorization processes, that inappropriately limit or impede access to medically necessary covered services. Prior authorization processes, in particular, have faced significant scrutiny for years. In 2022, the American Hospital Association published a letter asking DOJ to create a task force focused on FCA investigations into this very issue. Last year, lawmakers reintroduced a bill designed to simplify this process and just yesterday, the Senate Special Committee on Aging held a hearing that discussed it. As of yet, there have been no public FCA lawsuits addressing this risk area.
  • Providing improper financial incentives related to marketing and enrollment of Medicare Advantage beneficiaries. This has been a hot button area for FCA enforcement. Just last May, the DOJ filed a complaint against the three largest health insurance companies and three large insurance broker organizations alleging the insurers paid hundreds of millions in illegal kickbacks to the brokers in exchange for enrolling beneficiaries in Part C programs. There have also been several settlements in this space and HHS OIG has published a Special Fraud Alert on this practice.
  • Engaging in deceptive marketing practices that improperly mislead or deceive individuals to enroll in MA plans.
  • Submitting improper and/or false risk-adjusting diagnoses, or failing to retract such diagnoses after they have been submitted. This has been an area of FCA enforcement for over fifteen years and continues to remain an enforcement priority for DOJ. Our attorneys have represented five successful whistleblowers in False Claims Act settlements resolving allegations of a range of abusive risk adjustment practices in the MA program. Just last month, the DOJ settled a risk-adjustment fraud case against Kaiser for $556 million, which involved claims brought by our whistleblower client Dr. James Taylor, M.D., and continues to pursue risk-adjustment fraud cases against UnitedHealthcare, which was launched by our client, and Anthem/Elevance, among others.
  • Providing inaccurate quality and performance information to CMS, including for Star Ratings, or failing to meet quality metrics, like the health outcomes survey or accreditation scorecards.
  • Failing to appropriately control and oversee third parties, including improperly delegating certain compliance functions to FDRs (First Tier, Downstream or Related Entities).

The report further notes that these priority risk areas are in addition to the ones identified in its 1999 guidance document, stating “[t]he absence of a previously identified risk area or consideration . . . does not signal that a risk no longer exists, has become irrelevant, or is otherwise inapplicable.”

False Claims Act Liability for Medicare Advantage Fraud

Not only is the FCA an important deterrent to fraud, it is also a critical mechanism to recover funds previously lost to fraud, waste, and abuse. Between 1986 and 2025, the government recovered more than $85 billion under the law, of which $60 billion came from healthcare fraud cases. Over 77% of those recovered healthcare dollars came from whistleblower-initiated lawsuits.

The attorneys at Whistleblower Partners have extensive experience representing whistleblowers in cases involving healthcare fraud. If you would like more information or wish to speak to an attorney at Whistleblower Partners, please contact us for a confidential consultation.