2026 has already seen healthcare risk adjustment settlements in the news, starting with the Department of Justice (DOJ) press release on Jan. 14 announcing a large settlement Kaiser Permanente Affiliates Pay $556M to Resolve False Claims Act Allegations, for Medicare Advantage (MA) Risk Adjustment (see the link in the references). This was followed by another press release on Jan. 20 from Goldberg Kohn announcing a settlement with Kaiser, “Goldberg Kohn Clients Part of Landmark Settlement with Kaiser for Alleged Risk Adjustment Fraud (see the references).
In the latter case against Kaiser Permanente were allegations of fraud with the reporting of diagnosis codes under the Affordable Care Act (ACA) HHS HCC model.
This all started back in 2013 with a complaint filed by a Kaiser employee Ronda Osinek, who worked in Northern California within The Permanente Medical Group (TPMG). Later that same year a subpoena was issued to Kaiser and an investigation was launched. Several other complaints were filed against Kaiser, including in 2018 a complaint was filed by former employees of Kaiser Gloryanne Bryant (myself) and Victoria Hernandez, under seal, so it was unknown to each of the “Relators” of the other filings. The court and government would later consolidate the cases and designate those in which they would “intervene” and “decline.”
It should be noted that the Jan. 14 DOJ Press Release did not mention or include the Bryant- Hernandez Kaiser case and only the first-to-file relators (Ronda Osinek and Dr. James Taylor) are specifically mentioned. The Bryant – Hernandez (our) case involving the Affordable Care Act was “declined” and thus not mentioned in their press release. However, we decided to pursue our “declined” case without active assistance from the DOJ. This is permitted under the False Claims Act (FCA). In a declined case, relators can litigate their claims on behalf of the government even if the government has not intervened in it, which was what we did. As Relators we also did assist the government in their case against Kaiser. We provided interviews, information, times/dates, names, titles, and files regarding documentation and coding practices for both MA and ACA encounters. We sat for depositions taken by Kaiser’s lawyers where we answered questions about both MA and ACA encounter documentation and coding.
One can see when reading the government complaint (see the link below) that there are several Health Information Coding and Clinical Documentation Integrity (CDI) areas that were a focus. Within the government’s intervened case “Settlement” document are the actual terms and conditions of the DOJ MA Risk Adjustment settlement which was agreed to by all parties involved. The settlement of the Kaiser FCA ACA case is confidential and is not public.
These two FCA settlements, however, are a strong wakeup call across healthcare whether a hospital, physician practice, or a health plan.
Kaiser Permanente FCA Complaint
Kaiser Permanente FCA Agreement
One of my favorite resources is Insights, distributed by Kodiak. Let me begin by noting that I do not have any affiliation with Kodiak. I
As discussed in my prior articles, Medicare Advantage (MA) organization payments incorporate a beneficiary’s health risk, as determined by diagnoses that map to Centers for
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