False Claims Act Updates 2026: DOJ Enforcement, Whistleblowers, and Compliance Strategies

The False Claims Act (FCA) is the federal government's most powerful civil enforcement tool against healthcare fraud, and the stakes have never been higher. In the fiscal year ending September 30, 2025, the Department of Justice recovered more than $6.8 billion under the FCA, the highest single-year total in the statute's history, with over $5.7 billion tied directly to the healthcare industry (DOJ, Jan. 2026). Whistleblower lawsuits surged to nearly 1,300, a roughly one-third increase in a single year. For any organization that bills Medicare, Medicaid, or TRICARE, this is the enforcement environment you operate in today.

This webinar cuts through the legal complexity and shows healthcare professionals exactly where the risk lies and what to do about it. We begin by demystifying two concepts that catch even well-intentioned providers off guard: what actually makes a claim "false" under the FCA, including why no specific intent to defraud is required, and the direct statutory link that turns every Anti-Kickback Statute violation into a False Claims Act violation. We then analyze four recent real-world settlements, including Aetna's $117.7 million Medicare Advantage risk-adjustment resolution and a kickback case that became false claims by operation of law. You will leave with practical, ready-to-use checklists for documentation, coding, and Medicare Advantage risk adjustment, along with a clear framework for building internal reporting systems and whistleblower protections that catch problems before they become federal cases.

• Summarize the current False Claims Act (FCA) enforcement landscape and recent Department of Justice trends. 
• Define what makes a claim "false" under the civil False Claims Act. 
• Explain why specific intent to defraud is not required to establish FCA liability. 
• Explain the statutory connection between the Anti-Kickback Statute and the False Claims Act. 
• Analyze recent multi-million-dollar healthcare fraud settlements and identify the compliance lessons they provide. 
• Identify common compliance risks involving Medicare, Medicaid, and TRICARE claims. 
• Apply practical compliance checklists to strengthen documentation, coding, and billing practices. 
• Describe the qui tam whistleblower process and the protections available to whistleblowers. 
• Identify the essential elements of an effective internal reporting and compliance program. 
• Recognize an organization's affirmative obligation to investigate, report, and repay identified overpayments. 
• Evaluate Medicare Advantage risk adjustment documentation and coding practices to reduce FCA exposure. 
• Develop proactive strategies to detect, prevent, and mitigate False Claims Act risks before they result in government investigations or enforcement actions.

• False Claims Act Enforcement 
• DOJ priorities 
• Recent trends 
• Healthcare focus 
• FCA Liability Standards 
• False claims 
• Knowledge standard 
• Materiality 
• No Intent to Defraud Requirement 
• Civil liability 
• Reckless disregard 
• Anti-Kickback Statute Connection 
• Statutory linkage 
• Referral payments 
• Compliance risks 
• FCA Penalties 
• Civil penalties 
• Treble damages 
• Exclusion risk 
• Documentation Risks 
• Medical necessity 
• Record accuracy 
• Provider signatures 
• Audit trail 
• Coding Compliance 
• Code selection 
• Modifier usage 
• Upcoding 
• Downcoding 
• Medicare Advantage Risk Adjustment 
• HCC coding 
• Diagnosis support 
• Risk scores 
• Chart reviews 
• RADV audits 
• Current Enforcement Case Studies 
• Settlement analysis 
• Lessons learned 
• Risk indicators 
• Whistleblower (Qui Tam) Process 
• Filing process 
• Government review 
• Relator awards 
• Case outcomes 
• Anti-Retaliation Protections 
• Employee rights 
• Protected activity 
• Employer obligations 
• Internal Reporting Systems 
• Reporting channels 
• Anonymous reporting 
• Escalation process 
• Investigation workflow 
• Corrective actions 
• Overpayment Obligations 
• Identification 
• Investigation 
• Timely repayment 
• Compliance Best Practices 
• Staff training 
• Policy updates 
• Routine audits 
• Risk monitoring 
• Leadership oversight 
• Documentation reviews 
• Reducing FCA Risk 
• Preventive controls 
• Compliance culture 
• Continuous improvement
• Interactive Q&A session after the webinar and receive direct answers from our expert speaker.

• Physician Owners 
• Medical Directors 
• Practice Administrators 
• Practice Managers 
• Compliance Directors/Officers 
• Compliance Managers 
• Revenue Cycle Directors 
• Revenue Cycle Managers 
• Billing Managers 
• Coding Managers 
• Billing & Coding Staff 
• Medical Coders 
• Medical Billers 
• Billing Company CEOs 
• Healthcare Consultants 
• Compliance Consultants 
• Internal Audit Directors 
• Risk Management Directors 
• Medicare Advantage Program Managers 
• Hospital and Health System Executives

Nicole Statley, CPCO, CPC, CPMA, has spent almost 20 years in the healthcare management industry. She has been involved in nearly every aspect of healthcare operations, including clearinghouse management, medical billing, coding, auditing, and compliance. Nicole provides consulting on topics such as HIPAA, CMS/OIG compliance, third-party vendor oversight, breach mitigation, and payer billing and coding guidelines. She currently holds professional certifications in Compliance, Medical Auditing, and Medical Coding. She is passionate about helping organizations not only achieve compliance but also feel supported throughout their compliance journey.