DOJ Claws Back $5.7B in Healthcare Fraud , A Record Year
The DOJ's FY2025 False Claims Act recoveries hit $5.7 billion in healthcare alone,more than triple the $1.7B collected in 2024 and the highest single-year total in FCA history. Healthcare drove roughly 84% of all FCA recoveries across every industry.
The whistleblower pipeline is exploding: 1,297 qui tam cases were filed (up from 980 in 2024), with whistleblowers collecting $262M in healthcare cases. Former employees know they can pocket 15–30% of whatever the feds recover. Biggest scalps: Omnicare (CVS subsidiary) , $949M for dispensing meds without valid prescriptions; Teva Pharma , $450M for kickbacks; Independent Health , $98M for bogus MA diagnostic codes; Seoul Medical Group , $62M for fabricating spinal diagnoses to inflate risk adjustment payments.
The DOJ flagged expanded enforcement in managed care, prescription drugs, and medically unnecessary care,exactly where SNFs operate. Cases take years to resolve; the compliance culture you build today determines whether you're reading about someone else's settlement in 2035 or writing a very large check.
CMS Is Done Trusting Your Fall Reporting
According to the OIG, roughly half of all falls with major injury in SNFs were never reported on the MDS. A peer-reviewed study confirmed only 57.5% of major-injury falls in Medicare claims appeared in MDS assessments; in home health, just 45%. CMS has spent 18 months building a fix.
In May 2025, a CMS Technical Expert Panel evaluated two approaches to redesign the Falls with Major Injury quality measure. Approach 2 keeps MDS as the fall source but cross-references hospital/ER claims to catch unreported injuries. Approach 4 bypasses MDS entirely,if claims show a fall-related injury code plus a major injury diagnosis, it counts even if the facility reported nothing. The panel split 50/50.
Meanwhile, the October 2025 RAI Manual (V1.20.1) expanded definitions: falls now include intercepted falls, resident-on-resident incidents, and falls outside the building. Major injuries now explicitly cover traumatic fractures, dislocations, head injuries, organ trauma, crush injuries, and spinal cord injuries. In January 2026, CMS revised the Special Focus Facility program to weight falls more heavily in selecting facilities for additional oversight.
Bottom line: CMS is matching your MDS against hospital claims. If a resident falls Tuesday and hits the ER Wednesday with a hip fracture, they will find it. You'd rather report it yourself than have CMS discover it for you. Or you could always have MedElite keep an eye on this stuff for you.
MA Plans Collected $23.67B in Payments They Couldn't Document
Medicare Advantage plans collected $23.67 billion in risk-adjusted payments they couldn't back up with medical records. The mechanism: MA plans get paid more for sicker patients, incentivizing chart reviews that "discover" diagnoses nobody knew about,turning a cough into chronic pulmonary disease or knee pain into a vascular code. When auditors asked for documentation, nearly $24B worth of claims came up empty.
The irony for SNF operators: these same plans deny your claims for insufficient documentation, require prior auth for basic equipment, and let utilization review nurses who've never visited your building override your medical director's judgment,while they collect billions they can't justify themselves.