Whistleblowers are your early-warning system
Most of these cases were initiated by employee, competitor, or patient whistleblowers under the False Claims Act's qui tam provisions. A robust internal disclosure program (with genuine non-retaliation protections) is the best way to surface problems before the DOJ does. The FCA's relator share creates a powerful incentive for employees to go to the government when they can't reach leadership.
Relevant: Kinex, Advanced Urology, Modern Nuclear, Semler, Fresno Community, Matrix, and others
Medical-necessity documentation is a billing matter
Multiple CIAs involve billing for tests or procedures that were medically unnecessary or not performed. Every ordered test or procedure needs a contemporaneous clinical rationale in the record. High-frequency tests (urine drug testing, respiratory panels, wound-care procedures) are OIG audit priorities; audit your own ordering patterns against clinical benchmarks before regulators do.
Relevant: Bethany, Dr. Malone, VHS Holdings, Advanced Urology, Kinex, Patient Choice, Semler
Any financial arrangement with a referring physician requires FMV
Several CIAs involve improper financial arrangements with physicians, from above-FMV supervision fees (Modern Nuclear) to physician bonuses for referrals (Fresno) to kickbacks disguised as marketing fees (Patient Choice). All compensation to physicians who can refer (employment, co-management, supervision, hospitality, technology subsidies) must be at fair market value, commercially reasonable, and documented before execution.
Relevant: Modern Nuclear, Fresno Community Hospital, Patient Choice Labs, NUWAY
Risk-adjustment coding must match the clinical record
Matrix Medical Network ($36.5M) submitted diagnosis codes to Medicare Advantage where the assessment forms didn't contain enough clinical information to support them. For any MA plan, ACO, or value-based contract where diagnosis coding affects payment, each submitted code must be supported by the contemporaneous record. Retrospective coding enhancements without documentation are a known OIG and DOJ target.
Relevant: Community Care Health Network (Matrix)
Quality-of-care failures are also FCA violations
Several nursing-home and disability-services CIAs show that accepting Medicare/Medicaid payment while providing objectively substandard care (understaffing, neglect, failure to meet minimum standards) is itself a False Claims Act violation under the "worthless services" doctrine: if the care is so deficient it has no value, the claims are false. Staffing adequacy is a billing-compliance matter, not just a quality metric.
Relevant: Center for Disability Services, Moroun/Villa, American Health Foundation, Riverpark/Avamere
Controlled-substance oversight is a federal compliance obligation
Walgreens ($300M) and Dr. Kabakibou ($3.5M) show that pharmacies and physicians face concurrent FCA and Controlled Substances Act liability. Pharmacies must maintain and act on suspicious-prescription monitoring. Physicians must be present when signing controlled-substance prescriptions and document medical necessity for every opioid order. Pre-signed prescription pads are both a CSA violation and a source of false Medicare claims.
Relevant: Walgreen Co, Kamal Kabakibou