▪ HEALTHCARE FRAUD ADVISORY FILE NO. WBP-HC-FRAUD-2026
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Medicare · Medicaid · TRICARE · Anti-Kickback · Stark

Where the
money is.

Healthcare fraud is the largest single source of False Claims Act recoveries and has been for more than two decades. Of the $6.8 billion the Department of Justice recovered under the FCA in fiscal year 2025, the majority came out of the healthcare industry — hospitals, nursing homes, pharmaceutical manufacturers, Medicare Advantage insurers, durable medical equipment suppliers, laboratories. In Louisiana, where Medicaid enrolls roughly one in three residents, the state-level version of this problem has a statute of its own.

The framework

Three statutes do most of the work.

Healthcare fraud cases generally rest on one or more of three federal laws, working in combination. The False Claims Act provides the cause of action and the qui tam mechanism. The Anti-Kickback Statute and the Stark Law define a lot of what counts as "fraud" in the first place.

The False Claims Act (31 U.S.C. § 3729)

The vehicle. Every bill submitted to Medicare, Medicaid, or TRICARE is a "claim" under the FCA. When the claim is false — because the service wasn't provided, wasn't medically necessary, was upcoded, or was tainted by an illegal referral — the claim is actionable. Treble damages. Per-claim penalties between $14,308 and $28,619. Relator share of 15–30%.

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b)

The AKS makes it a crime to offer, pay, solicit, or receive anything of value to induce referrals of items or services payable by a federal healthcare program. Since 2010, any claim that results from an AKS violation is automatically a false claim under the FCA — Congress wrote that rule directly into the statute. That single amendment is why so many healthcare FCA cases are built on kickback theories.

The Stark Law (42 U.S.C. § 1395nn)

Narrower and stricter than the AKS. Stark prohibits physicians from referring Medicare patients for certain designated health services to entities with which the physician (or an immediate family member) has a financial relationship, unless an exception applies. Stark is strict liability — intent doesn't matter. If the financial relationship exists and no exception fits, every claim for that referral is a false claim.

The patterns

What healthcare fraud actually looks like.

Upcoding

Billing Medicare or Medicaid for a more expensive service than was actually provided. A 15-minute office visit billed as a 45-minute complex consultation. A routine imaging study billed as the contrast-enhanced version. This is the single most common pattern across hospital and physician-practice cases.

Medically unnecessary services

Procedures, tests, imaging, therapy sessions, or hospital admissions that were not justified by the patient's condition — ordered because they were reimbursable, not because they were needed. Cardiology, oncology, and rehabilitation have all generated major cases. Nursing home therapy cases — where facilities pushed patients into the highest Medicare reimbursement tier regardless of clinical need — have produced some of the largest recoveries of the last decade.

Kickbacks and self-referrals

Sham medical director agreements. Above-fair-market-value rent. Speaker bureaus that pay physicians for referrals dressed up as "education." Free staff or supplies to referring practices. Investment interests in the entities a physician refers to. The fact patterns vary; the core question is always the same — did something of value change hands, directly or indirectly, because of referrals?

Medicare Advantage risk-score gaming

Medicare Advantage insurers are paid more by CMS when their enrollees appear sicker — higher risk-adjustment scores translate directly into higher capitated payments. Several of the largest FCA cases now pending involve insurers that allegedly coded diagnoses their members didn't actually have, or failed to delete diagnoses they knew were unsupported after chart review. This is currently the single most active enforcement area in healthcare fraud.

Nursing home fraud

In Louisiana and across the South, this is a dominant fact pattern. Schemes include billing for services not provided, worthless services (care so deficient it amounted to no care at all), phantom residents, and inflated therapy-minute reporting. The Department of Justice has specifically prioritized nursing home cases, and MAPIL reaches nursing facilities that receive Louisiana Medicaid funds.

Pharmaceutical and device fraud

Off-label marketing — promoting a drug for uses the FDA has not approved and that are not reimbursable under federal healthcare programs. Best-price violations under the Medicaid rebate statute. Average-manufacturer-price manipulation. Kickbacks to prescribers disguised as speaker fees, advisory-board payments, or consulting contracts. The largest individual FCA recoveries in history have come from this category.

Laboratory and DME schemes

Telehealth-driven durable medical equipment fraud exploded during the pandemic and remains a major enforcement focus. The pattern: a telemarketing company generates "leads," a telehealth doctor signs orders for braces or genetic tests without meaningful patient interaction, a DME supplier or lab bills Medicare, and everyone takes a cut. Every link in the chain can be liable under the AKS and the FCA.

Hospice fraud

Enrolling patients in hospice who are not terminally ill. Hospice pays on a per-day basis regardless of services provided, which creates a powerful incentive to recruit and retain ineligible patients. The pattern has produced settlements in the hundreds of millions.

Louisiana specifics

Why healthcare fraud cases in Louisiana often have two tracks.

Louisiana's Medicaid program is one of the largest in the country relative to its population. Roughly 1.6 million Louisiana residents are enrolled in Medicaid or LaCHIP, and the program is administered primarily through private managed-care organizations. That structure creates two separate sources of False Claims Act liability for any given fraudulent scheme.

If a Louisiana nursing home bills Medicare for worthless services, that is a federal False Claims Act case. If the same nursing home also bills Louisiana Medicaid for the same worthless services, that is a MAPIL case. The two statutes are usually filed together, in the same sealed complaint, with two separate relator shares running in parallel. The federal share is 15–30% of the federal recovery. The MAPIL share is 15–30% of the state recovery. Both shares go to the same relator.

Louisiana Medicaid MCO fraud is its own category.

Louisiana delivers most of its Medicaid through five managed-care organizations. Those MCOs receive capitated per-member payments. Fraud at the MCO level — inaccurate encounter data, improper denials of care to preserve margin, network inadequacy concealed from the state — is covered by MAPIL directly. See the Louisiana MAPIL page for detail.

Who the best whistleblowers are

The people who see healthcare fraud first.

Certain roles have visibility into healthcare fraud that nobody else has. If you held one of these positions and something didn't add up, you are exactly the person the statute was written for.

  • Billers and coders. You see the gap between what was documented and what was billed. You are usually the first to know when the numbers are wrong.
  • Compliance officers and internal auditors. Your job was to flag problems. If the organization ignored or buried your findings, that pattern often itself strengthens a case.
  • Sales representatives. In pharmaceutical, device, and DME cases, sales reps are usually the only people who know what was actually said to physicians about off-label uses, speaker programs, or referral arrangements.
  • Nurses and therapists. Direct-care staff see the mismatch between what was done for the patient and what the facility billed. Nursing home and rehabilitation cases almost always start here.
  • Physicians. Physicians see upcoding, unnecessary procedures, and kickback arrangements from the inside. Physician-relator cases often carry the most credibility in court.
  • IT and data analysts. Risk-score gaming cases and MCO cases often depend on internal analytics that only a handful of people ever see. If you ran the queries, you may have the case.
If you saw something at work

Healthcare fraud cases are almost always built from the inside.

The government's ability to detect these schemes on its own is limited. Claims data shows anomalies but rarely proves intent. Insiders provide the context that turns an audit finding into a case. Federal anti-retaliation protections under § 3730(h) and Louisiana protections under La. R.S. 46:440.3 were written for this reason.

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