2026 GAHA Annual Meeting and Health Law Update-2

2 - Internal Investigations

Pdf Summary

The presentation focused on enforcement trends under the False Claims Act (FCA), internal investigations, and emerging whistleblower risks in healthcare. It highlighted that FCA recoveries exceeded $6.8 billion in 2025, the highest annual total ever, with qui tam whistleblower cases accounting for most recoveries and healthcare driving over 83% of the total.<br /><br />Recent enforcement examples showed the importance of compliance and self-reporting. In one Arizona surgical hospital matter, entities paid $5.6 million over alleged FCA violations tied to improper financial relationships that implicated the Anti-Kickback Statute and Stark Law; the DOJ credited cooperation after disclosure following an internal review. A physical therapy company paid nearly $5 million over upcoding allegations, with a whistleblower receiving a significant relator share. Kaiser Permanente affiliates agreed to pay $556 million over allegations they submitted invalid diagnosis codes for Medicare Advantage risk adjustment, allegedly driven by aggressive internal pressure and ignored warnings.<br /><br />The presentation then explained why companies conduct internal investigations: to identify and remediate issues, respond to complaints or government inquiries, and assess whether existing policies were followed or need improvement. It emphasized defining the scope early, considering insurance and reporting obligations, selecting the right investigators, preserving relevant data, and gathering facts through documents and employee interviews. It also noted the importance of Upjohn warnings, privilege concerns, and deciding whether to produce a written report or oral findings.<br /><br />Finally, the presentation addressed future risks, including AI and data-mining whistleblowers. It noted that many new qui tam filings now originate from data-mining entities using public data and statistical models, and discussed the DOJ’s FOCUS Initiative, which encourages sophisticated data analysis to detect fraud.

Keywords

False Claims Act

FCA recoveries

qui tam whistleblowers

healthcare enforcement

internal investigations

Anti-Kickback Statute

Stark Law

upcoding allegations

Medicare Advantage risk adjustment

AI whistleblower risks