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In fiscal year 2025, settlements and judgments under the False Claims Act exceeded $6.8 billion, the highest single-year total in the law's history. More than $5.7 billion was tied to healthcare fraud. Congress enacted the False Claims Act to protect the federal government's financial interests. Among its provisions is a qui tam action, which permits private individuals to file lawsuits on the government's behalf.
Below are common types of False Claims Act cases in healthcare and what recent settlements mean for healthcare whistleblowers.
Upcoding and Billing Fraud
Upcoding is the practice of billing Medicare, Medicaid, or other federal healthcare programs for more expensive services than were actually provided, and it is one of the most common forms of healthcare fraud.
In November 2025, Vohra Wound Physicians consented to pay $45 million to resolve allegations of a nationwide scheme to submit Medicare claims for medically unnecessary and upcoded wound care services. The government alleged that Vohra programmed its billing software to automatically bill for higher-reimbursed surgical procedures regardless of the care provided. These are allegations only, and there has been no determination of liability.
Illegal Kickbacks
Kickbacks are payments or incentives used to influence referrals for items or services covered by Medicare, Medicaid, or other federal programs. The Anti-Kickback Statute prohibits this conduct.
In January 2025, Pfizer agreed to pay nearly $60 million to resolve allegations that its subsidiary, Biohaven Pharmaceutical, had paid physician speaker honoraria and provided meals at high-end restaurants to induce prescriptions of the migraine drug Nurtec ODT. The case originated from a qui tam lawsuit filed by a former Biohaven sales representative. These are allegations only, and there has been no determination of liability.
Unnecessary Medical Procedures
Billing for unnecessary medical procedures, such as tests or treatments not medically indicated, is another prevalent form of healthcare fraud. Medicare and Medicaid reimburse only for medically necessary services, and providers who submit claims outside that standard may face liability under the False Claims Act.
In March 2025, Diopsys Inc. agreed to pay up to $14.25 million to resolve allegations that it caused providers to submit false claims for medically unnecessary vision tests using a device that lacked FDA clearance for those uses. These are allegations, and there has been no determination of liability.
Hospice Fraud
Hospice fraud typically involves enrolling patients who do not meet Medicare's eligibility threshold — a life expectancy of six months or less if the illness follows its normal course — and billing for their care as though they were terminally ill.
In February 2025, Saad Healthcare agreed to pay $3 million to resolve allegations that it submitted false Medicare claims for 21 hospice patients in Alabama who were not terminally ill. The case was brought as a qui tam action by two former Saad employees. These are allegations only, and there has been no determination of liability.
What These Cases Mean for Whistleblowers
A whistleblower who comes forward with evidence of healthcare fraud plays an essential role in protecting federal programs and the patients who depend on them. Whether the scheme involves upcoding, kickbacks, unnecessary medical procedures, or hospice fraud, those with direct knowledge of billing practices are often best positioned to expose it.
If you have witnessed any of these fraudulent activities, contact the experienced whistleblower attorneys at Goldberg Kohn today for a free and confidential consultation.