A public-interest watchdog & educational resource for California Medi-Cal members Not affiliated with the State of California or any health plan
For health plan employees · plain English · every claim sourced · not legal advice

If your health plan commits fraud, can you be blamed for it?

The order disappears. Your login doesn't.

Short answer: if you truly didn't know, the law mostly treats you as the tool, not the crook. Once you know, it can treat you as a partner. And the proof of what you did is saved under your name.

The 60-second version → Asked to do something? Start here
  • The order disappears.It comes by phone, in a meeting, or in a chat set to delete itself.
  • Your login doesn't.Letters, codes, notes and overrides are usually logged under your employee ID.
  • The company's lawyer isn't yours.In an investigation, the company gets credit for naming the people involved.

Published November 2, 2026 · Last reviewed November 2, 2026

If you only read one thing

The 60-second version

Six lines

  1. Companies don't click buttons. People do. Denials, letters, diagnosis codes and "unable to contact" notes are usually logged under somebody's employee ID.
  2. Bad orders rarely come in writing. They come by phone, in a meeting, or in a chat that disappears. Your work in the system stays.
  3. Didn't know? You're the tool. Knew? You're a partner. The law draws the line at what you knew, or worked hard not to know.
  4. You already agreed to the rules. The big plans' codes of conduct say: follow the law, report problems, cooperate with every investigation.
  5. When investigators come, the company trades names for credit. Justice Department policy rewards a company for naming everyone involved, "regardless of their position, status, or seniority."
  6. It can come back years later. The safe moves are early ones: don't do it, write it down, get your own lawyer.

You don't become a target by working at a plan. You become one by doing what you know is wrong, or by lying about it later.

How it works

How a company does fraud with your hands

In plain words A company can't commit fraud by itself. It needs people to press the buttons. Most of them never know what the buttons are for.

Think of movers

A man hires a moving crew to carry a TV out of a house. He says it's his. If the movers believe him, they aren't thieves. He is. But if they saw the broken window and kept carrying, the law says they knew.

That idea is old, and it is written into federal law: whoever "willfully causes an act to be done" that would be a crime is guilty as if they had done it themselves. In 1937 the Supreme Court upheld the conviction of a bank teller who hid deposit slips so that bookkeepers, who knew nothing, made false entries. The bookkeepers made the entries. The conviction was the teller's.

Here is the catch. The person who gave the order is guilty, but someone has to prove who that was. Orders are spoken. Your keystrokes are logged.

How the order travels

  1. A target is set"Cut the refund to zero." "Clear the backlog by Friday."
  2. A manager passes it onSaid on a call. Typed in a chat set to delete.
  3. You do it in the systemSaved with your login, the date and the time.
  4. The company signs a report"All notices on time." "Spending on target."
  5. Money movesKept instead of refunded. Paid when it wasn't owed.

How investigators trace it back

  1. The moneyWhere did it go?
  2. The reportWho signed it? What was it built from?
  3. The system logsWhich records? Changed when?
  4. The employee IDsWhose login touched them?
  5. "Who told you?"If nothing is written down, the trail stops at the login.
The spoken order is the weakest link in the record. The keystroke is the strongest.

18 U.S.C. § 2(b); United States v. Giles, 300 U.S. 41 (1937).

Alleged

"... we don't really want to put this in writing?" In a 2025 False Claims Act complaint, the Justice Department quotes insurer staff steering sensitive talk away from paper. A Humana employee wrote, "I am assuming you want us to have this dialogue over the phone as I recall that we don't really want to put this in writing?" The complaint also quotes an Anthem executive telling staff that "[a]bsolutely nothing in writing or in verbal conversations internally or externally can refer to this as a bonus." The case is against Aetna, Elevance Health, Humana and three brokers. The defendants deny the claims, and nothing has been decided.

U.S. ex rel. Shea v. eHealth, Inc., No. 1:21-cv-11777 (D. Mass.), complaint in partial intervention, May 1, 2025, ¶¶ 326, 585.

The person who gives the order is guilty of it. The trouble is proving who that was, when the only name in the log is yours.

Where the line is

Didn't know, looked away, or knew

In plain words The law cares most about one thing: what was in your head when you did it.

  1. You didn't know

    You did what you were told and had no reason to think it was wrong. The law treats you as the tool, an . Being careless or foolish is not the same as knowing.

    18 U.S.C. § 2(b); Ninth Circuit model jury instruction on deliberate ignorance

  2. You suspected and looked away

    You strongly suspected something was wrong and took steps not to find out. Courts call that and treat it as knowing. In a False Claims Act case, "deliberate ignorance" and "reckless disregard" count too, with "no proof of specific intent to defraud."

    Global-Tech Appliances v. SEB, 563 U.S. 754 (2011); 31 U.S.C. § 3729(b)(1)

  3. You knew, and did it anyway

    "My manager told me to" is not a defense. In California, the law that makes your employer cover the cost of following its orders, "even though unlawful," stops if "the employee, at the time of obeying the directions, believed them to be unlawful."

    Cal. Labor Code § 2802(a)
"No employee, regardless of his or her position, is ever authorized to commit, or direct another employee to commit, an unethical or illegal act."
UnitedHealth Group, Code of Conduct, December 2025, p. 6

Most people at a plan stay in the green zone their whole careers. This page is for the day someone asks you to step out of it.

What it sounds like

Felonies in disguise: the ask, and what it really is

In plain words Nobody says "commit fraud." They say something that sounds like a deadline. Here is what those requests can turn into.

  • Convicted or pleaded guilty
  • Acquitted
  • Settled no admission
  • Admitted settled with admissions
  • Finding regulator or court
  • Report government audit
  • Alleged not decided
  • Reporting journalism
  • Watch for no public case

Letters & mail

"Run the batch. Hold the print file."

What it is
A notice the system says exists, that the member never gets. The rule says the plan must mail it, and the member's 60 days to appeal start from the date printed on it.
What it can be
A false record behind a claim (31 U.S.C. § 3729(a)(1)(B)); a false statement in a health care matter (18 U.S.C. § 1035).
On the record
Report Louisiana Healthcare Connections, a Centene plan: for 11 of 76 sampled denials, members got no written notice, because a written internal policy sent notices for these hospital-stay denials only to the providers. The plan removed that exception in June 2023, and OIG's report title says it "generally complied" (HHS-OIG, March 2026). Nothing in the report suggests mail was held back. Finding A Medicare plan held back a required member mailing because it "believed that all enrollees ... would be reassigned"; CMS imposed a $45,000 penalty (2009). Watch for Batches deliberately pulled before mailing. How it works ↓

Letters & mail

"Date it for the 14th." · "Just clear the failed-fax queue."

What it is
A letter that says it went out on time when it didn't, or a notice that quietly dies in a queue.
What it can be
A false statement in a health care matter (18 U.S.C. § 1035). Once an investigation is possible, changing a record to affect it is its own felony, up to 20 years (18 U.S.C. § 1519).
On the record
Report At an Oregon Medicaid plan, a subcontractor's fax of a denial notice to a provider failed twice; "on the third day, the subcontractor deleted the failed fax," and the notice was never mailed to the provider (HHS-OIG, August 2026). The member did get a written notice; it was the provider's copy that was lost. Watch for Backdated letters: no public enforcement found yet.

Care management

"Just log it 'unable to contact.'"

What it is
A call or visit that never happened, on the record as if it did. Centene's own code of conduct uses this exact example and calls it "misrepresenting whether or when a contact occurred."
What it can be
A false statement in a health care matter (18 U.S.C. § 1035). Plans owe new members screenings and care coordination on a clock (42 CFR § 438.208).
On the record
Admitted A New York long-term care plan admitted it "did not provide" required services or "did not adequately maintain documentation" of them while collecting monthly payments; $10.16 million; the whistleblower was a former employee (2024). Watch for Faked outreach logs: no public case yet.

Call center

"If they don't say 'grievance,' it's an inquiry."

What it is
A complaint that never reaches the State's numbers. A grievance is any expression of dissatisfaction about anything other than a denial or cut in services (those are appealed), whatever the member calls it.
What it can be
A false report to regulators. Plans must log and report every grievance (42 CFR §§ 438.400, 438.416).
On the record
Finding Anthem Blue Cross, January 2026: $15 million over long-running failures to identify and resolve grievances. Finding CMS penalized Point32Health in 2025 because "staff did not consistently identify and initiate coverage requests when enrollees called." The grievance playbook →

Clinical review

"Keep it inside the target." · "Pend it."

What it is
A medical decision made by a number, not by the patient in front of you.
What it can be
California now says only a licensed physician or licensed health care professional may decide medical necessity, and software may not "supplant health care provider decision making" (SB 1120, in force 2025).
On the record
Reporting STAT News, 2023: naviHealth set a target to keep Medicare Advantage rehab stays within 1% of an algorithm's projection, and employees who missed it risked discipline. UnitedHealthcare says the tool is a guide. Report HHS-OIG, June 2026: naviHealth denied 14% of skilled nursing admission requests it reviewed, and 97% of its denials that were appealed were overturned (data from June 2024). Alleged In the Lokken case, a March 2026 order compelled discovery, in part, on naviHealth employee incentives and discipline.

Medical director

"Just sign the batch."

What it is
Your name and your license on decisions you didn't make.
What it can be
For a California physician, "knowingly making or signing" a document "which falsely represents the existence or nonexistence of a state of facts" is unprofessional conduct (Bus. & Prof. Code § 2261). Centene's code: "You are accountable for any document you review and approve, even if the document did not originate with you."
On the record
Reporting ProPublica, 2023: Cigna doctors denied over 300,000 requests in two months, "spending an average of 1.2 seconds on each case." Cigna says the reviews happen after care is given.

Coding & chart review

"Send the addendum query." · "We only send adds, not deletes."

What it is
Diagnoses added to raise the payment, and wrong ones never taken back.
What it can be
Keeping money that is owed back (31 U.S.C. § 3729(a)(1)(G)); a false certification of payment data.
On the record
Settled Kaiser Permanente, January 2026: $556 million to resolve allegations that it sent doctors diagnosis "queries" "often months and sometimes over a year after visits"; no determination of liability. The whistleblowers were former Kaiser employees, one of them a physician. Finding CMS, February 2026: Elevance's coders found unsupported codes, but the corrections went to CMS "on external USB flash drives" while the company "continued to annually certify" its data. Elevance says it stands firmly behind its program; it paid CMS $342 million in May 2026, and CMS said in July it would not impose the sanctions. Settled Independent Health, 2024: the founder and CEO of its chart-review subsidiary, DxID, agreed to pay $2 million herself.

Sales & enrollment

"Don't sign up pregnant women."

What it is
Screening out members who cost more, so the plan keeps the monthly payment and skips the care.
What it can be
False claims for the monthly payments (31 U.S.C. § 3729), plus state law.
On the record
Finding Amerigroup Illinois: the Justice Department said a federal jury found in 2006 that it "illegally avoided pregnant women and other people with expensive health conditions." A 2001 email, reported by the Chicago Tribune, praised "the marketing reps of not trying to sign up pregnant women." The court entered a $334 million judgment. Settled The company settled in 2008 for $225 million without admitting liability. Amerigroup is now part of Elevance Health.

Finance & reporting

"Find a way to make it zero."

What it is
A refund owed to the State, made to disappear on a spreadsheet.
What it can be
Health care fraud (18 U.S.C. § 1347); false statements (§ 1035); keeping money owed back (31 U.S.C. § 3729(a)(1)(G)).
On the record
Convicted WellCare: according to trial evidence described by the court of appeals, an executive told analyst Greg West the team had been "charged by Todd Farha to find a way not to pay back 10 million dollars." West built the spreadsheets. He pleaded guilty in December 2007 and testified. Four executives were convicted in 2013 and a fifth pleaded guilty in 2017. All five executives were pardoned in January 2021. The analyst was not on that list. Alleged In September 2025 the Justice Department sued Inland Empire Health Plan, a Medi‑Cal plan, alleging false statements to Medi‑Cal to keep surplus Medi‑Cal Expansion money. The case is pending; the Justice Department says the claims are allegations only.

Provider data

"Mark them verified."

What it is
A directory, and a network filing to the government, that says doctors are available when they aren't.
What it can be
A false record behind the plan's contract and payments (31 U.S.C. § 3729(a)(1)(B)).
On the record
Settled Freedom Health, 2017: $31.7 million to resolve allegations of unsupported diagnosis codes and false network information given to CMS; the former chief operating officer agreed to pay $750,000 over his alleged role in the network scheme; no determination of liability. Settled People v. Health Net, 2025: a stipulated judgment and injunction on provider directories. Health Net denied wrongdoing and admitted nothing. Read it →

Everyone

"Let's take this to Signal." · "Delete that chat."

What it is
Moving the order where it can't be found, and leaving your work where it can.
What it can be
Deleting or hiding a record to obstruct a federal matter, including one only "in relation to or contemplation of" an investigation, is a felony, up to 20 years (18 U.S.C. § 1519). The Justice Department grades companies on whether they control "personal devices" and "ephemeral messaging applications." Elevance's code says it can access "any personal device used for company business" and release what it finds "to government agencies."
On the record
Pleaded guilty A sales executive at the records-software company Practice Fusion admitted "deleting from his company-issued laptop hundreds of computer files relevant to the investigation" in late 2019. He pleaded guilty in 2021 and was sentenced in 2024.

Everyone

"Just tell them it was a system glitch."

What it is
The interview. Lying to a federal agent is its own crime, even if you did nothing else wrong.
What it can be
A false statement to the government, up to 5 years (18 U.S.C. § 1001).
On the record
Convicted WellCare's vice president of medical economics agreed to a 90-minute interview in his office on the day of the 2007 raid. The jury could not agree on the conspiracy charge against him. It convicted him on two counts of making false statements to the agents. (He was among those pardoned in 2021.)

None of these asks sound like crimes. That is the point. The crime is in what the record says, and the record says your name.

A closer look

The letter that only exists in the computer

In plain words A notice can say "sent" in the system and never reach a mailbox. The member can lose rights they never knew they had.

What the system shows

  1. Service denied
  2. Notice generated, dated March 3
  3. Status: Sent
  4. On paper, the appeal window closes

What the member gets

  1. Nothing
  2. The pharmacy says "not covered"
  3. Calls the plan. Hears "it was denied in March"
  4. On paper, the window closes. Nobody told them it was open.

Why it works. The federal rule gives a Medicaid member 60 days to appeal "from the date on the adverse benefit determination notice." The count starts on the date printed on the letter, not the day it arrives. So on paper, a letter that never left the building can make a member's appeal look late before they know there is anything to appeal.

Why it's not allowed. Every denial needs written notice to the member, with the reasons and the right to appeal and to a State Fair Hearing. For rating periods starting on or after January 1, 2026, a standard decision is due within 7 calendar days (with a possible 14-day extension), 72 hours if urgent. When a plan cuts a service that was already approved, the notice has to go out at least 10 days ahead. A notice that was generated but never mailed hasn't been given.

How it gets caught. Printers and mail houses usually keep job logs. Mail with tracking barcodes is scanned. Returned mail is usually logged. Members show up at hearings and say "I never got it." And every hold, purge or filter in a print system was set by someone, at a time, under a login.

The moment to stop: if you're asked to hold, purge or "suppress" a batch of member notices, or change a date on one, stop. Write down who asked, when, and which batch.

Report Louisiana, March 2026: no written member notice for 11 of 76 sampled denials, under a written policy since removed. Report Oregon, August 2026: a failed fax deleted; a provider's denial notice never mailed. Finding CMS, 2009: a required mailing held back on a business assumption. Watch for Batches deliberately pulled before mailing: no public case.

We are not saying any plan or vendor does this. We are explaining how it would work and how it would be found.

A question for insiders. Can a system show a notice as generated while the letter never left the building, or was pulled before it was mailed? If you know how that works, we would like to understand it: tips@nosuchprovider.org.

42 CFR §§ 438.402(c)(2)(ii), 438.404, 438.210(d), 431.211; Cal. Welf. & Inst. Code § 10950 and following.

What you agreed to

The fine print you agreed to: where the trap is already set

In plain words Your code of conduct is a promise you made. In an investigation, it becomes proof of what you were told.

Plans require you to follow their code of conduct. Health Net staff must agree to theirs when hired, and Molina's must acknowledge theirs when hired and every year. We read the current codes of three parent companies that run Medi‑Cal plans: Centene (Health Net), Elevance Health (Anthem Blue Cross) and Molina Healthcare. Here is what they already say about you, word for word.

We're not saying these companies wrote their codes to trap anyone. Codes like these exist for good reasons, and they protect you when you follow them. We're showing how the words work once an investigation starts.

1 You must report, and staying quiet is a violation

Centene

"Failure to report an ethics or compliance issue may be as serious as committing the offense itself and may result in disciplinary action, up to and including termination."

2026 Code, p. 7

Elevance

"Reporting suspected or observed misconduct or other ethical concerns is a condition of our employment."

January 2026 Code, p. 6

Molina

"All employees and subcontractors must immediately report good-faith and reasonable suspicions related to a potential violation of any section of the Code."

Code amended July 2025, p. 4

2 If someone asks you to break the law, that's on you to report

Centene

"All directors, officers, and employees must understand that at Centene, we care how results are obtained, not just that they are obtained."

2026 Code, p. 10

Elevance

"We must never commit or ask others to commit unethical or illegal acts. We should immediately report any request or direction to commit an act we think may be illegal or unethical."

January 2026 Code, p. 5

Molina

"Employees and subcontractors must not allow non-compliant or risky issues or behavior to persist without reporting their concerns."

Code amended July 2025, p. 7

3 You are personally on the hook

Centene

"In addition to disciplinary action taken by the Company, an employee who fails to comply with applicable laws, regulations, requirements, or policies may be subject to civil and/or criminal liability."

2026 Code, p. 10

Elevance

"If we approve or participate in actions violating the Code, company policies and procedures, laws or regulations or fail to fully cooperate in an investigation, we are subject to corrective action."

January 2026 Code, p. 9

Molina

"Additionally, violating this Code might result in civil liability and/or criminal prosecution."

Code amended July 2025, p. 4

4 You must cooperate with the investigation

Centene

"If you are contacted in connection with an investigation, you must cooperate fully. This includes making yourself available for interview, providing timely, truthful, and complete information and documentation ..."

2026 Code, p. 8

Elevance

"We all have a duty to fully cooperate with an Ethics and Compliance investigation. We must provide all known information and must not withhold, destroy, or tamper with any records ..."

January 2026 Code, p. 9

Molina

"All employees and subcontractors will fully cooperate with any internal or external audit, review, or investigation."

Code amended July 2025, p. 8

5 Your records are evidence, and the company can hand them over

Centene

"The contents of Company assets may be disclosed to ... law enforcement, government officials, and legal counsel, without your knowledge or permission."

2026 Code, p. 18

Elevance

The company may "physically access any personal device used for company business to inspect, review and collect company information and to release such information to government agencies or third parties during an investigation or in litigation in the Company's sole discretion."

January 2026 Code, p. 16

Molina

Records "maintain evidence of our work and provide an audit trail of transactions and accountability for our work, allowing a user later in time to potentially replicate an activity or show how decisions were made."

Code amended July 2025, p. 19

6 You agreed to it, and you were trained on it

Centene

"Each Centene employee is required to complete annual FWA training to understand the importance of our program and their own role in preventing, identifying, reporting, and correcting FWA."

2026 Code, p. 13

Elevance

"It is our policy that any associates who fail to complete required training will face corrective action, up to and including termination of employment."

January 2026 Code, p. 5

Molina

"As a condition of employment, all employees are required to acknowledge their receipt and understanding of this Code when they are hired and annually thereafter."

Code amended July 2025, p. 4

How a company uses it

When prosecutors decide how to treat a company, they ask whether it had a real compliance program: a code, training, a hotline, and discipline. A company that can show all of that, plus your acknowledgment and your training record, can argue the problem was one employee, not the company.

Health Net's own 2026 Medi‑Cal compliance program describes the same logic. Self-reporting is "a mitigating factor ... if the reporting entity becomes the target of an outside investigation," and "Health Net will provide all evidence relevant to the alleged violation."

DOJ Criminal Division, Evaluation of Corporate Compliance Programs (Sept. 2024); U.S.S.G. § 8B2.1; Health Net Community Solutions, Compliance Program Description 2026, p. 22

What none of the three say

  • Whom the company's lawyers represent. None of the three codes says. The answer is the company.
  • That you can go straight to the government. Only Molina says it outright: "Nothing in this Code prevents you from communicating directly with relevant government authorities about potential violations of law." It also tells employees to notify its legal department of any government interview, and doesn't say how the two fit. Centene's code mentions only that the False Claims Act lets people "file suit on behalf of the government." Elevance's says neither.
  • That your legal bills will be paid. All three companies' governing documents make paying defense costs up front a duty for directors and officers. For other employees, paying up front is a "may." Elevance's and Molina's documents say employees "shall" be repaid afterward in some cases, such as when they acted in good faith, and Molina's bylaws cover the costs of an employee called as a witness. Your actual employer may be a subsidiary with its own rules.

Flip it

The code is also your shield

Every one of these codes forbids retaliation for a good-faith report. Elevance's tells you to "immediately report any request or direction to commit an act we think may be illegal." So use the words back:

"Our Code of Conduct says I have to report any request to do something I think may be illegal. Can you send me this request in writing so I get it right?"

The code works against the employee who follows the bad order, and for the one who follows the code.

If investigators come

When investigators come, the company protects itself first

In plain words The company has its own lawyers, its own deal to make, and a federal rulebook that rewards it for naming people.

  1. A subpoena, a demand letter, or agents at the door

    At WellCare, more than 200 federal and state agents searched the Tampa headquarters on October 24, 2007.

  2. A legal hold notice arrives

    It tells you to keep everything. Deleting or changing a record to affect a federal investigation is a felony of its own, up to 20 years, and it covers a record destroyed "in relation to or contemplation of" an investigation. The doesn't wait for the notice.

  3. The company hires outside lawyers to investigate itself

    They collect email, chats, system logs and audit trails, then interview employees.

  4. You're interviewed, and it starts with a warning

    It is often called an . Here is the version AOL's general counsel gave one manager, as quoted by a federal appeals court that then let a grand jury have the interview records:

    "We represent the company. These conversations are privileged, but the privilege belongs to the company and the company decides whether to waive it."

    The court called the company's warnings "watered-down," because the lawyers had also said they "could" represent him.

    In plain words: they are not your lawyers, and the company can choose to hand your words to the government. Even if it doesn't, to earn credit it must give prosecutors "relevant factual information—including relevant factual information acquired through those interviews."

    In re Grand Jury Subpoena: Under Seal, 415 F.3d 333, 336, 339–40 (4th Cir. 2005); Justice Manual 9-28.720 n.2

  5. The company trades facts about people for credit

    Since March 10, 2026, one Justice Department policy covers every corporate criminal case except antitrust. To get full , a company must disclose:

    "facts and evidence about all individuals involved in or responsible for the misconduct at issue, including individuals inside and outside of the company regardless of their position, status, or seniority"

    It must give "attribution of facts to specific sources rather than a general narrative of the facts," and make "officers, employees, and agents who possess relevant information available for interviews." In civil False Claims Act cases, it gets credit for "identifying individuals substantially involved in or responsible for the misconduct."

    Your clock

    120 days

    If you report inside the company first, you have 120 days to also report to the Justice Department and keep your place in line for an award under its corporate whistleblower pilot program. A False Claims Act whistleblower suit has no such grace period: the first to file generally holds the case.

    The company's clock

    120 days

    If you also report to the Justice Department, the company can still get its best deal only by self-reporting "as soon as reasonably practicable but no later than 120 days" after your internal report. Its report must name names.

    DOJ, Corporate Enforcement and Voluntary Self-Disclosure Policy (Mar. 10, 2026), App. B; Justice Manual 4-4.112; DOJ Corporate Whistleblower Awards Pilot Program guidance (rev. July 30, 2026) § II.2.d; 31 U.S.C. § 3730(b)(5)

  6. The company settles. People are handled separately.

    Acquitted In 2023 the Medicare Advantage plan HealthSun reported itself, cooperated and agreed to repay about $53 million, and the Justice Department declined to prosecute the company. In the same announcement, it said it had charged HealthSun's former Director of Medicare Risk Adjustment Analytics. A jury found her not guilty in June 2025.

    Convicted In 2009 WellCare signed a deferred-prosecution agreement promising to "fully cooperate" with the "continuing investigation of individuals responsible," and agreeing that the deal "in no way restricts the ability" of prosecutors to proceed "against any individual in any capacity." Executives were indicted in 2011. Four were convicted in 2013 and a fifth pleaded guilty in 2017. All five were pardoned in January 2021.

  7. Who pays your lawyer?

    The company may pay for your lawyer, and prosecutors aren't supposed to hold that against it. For most employees, paying as you go is a choice, not a promise. In California, the law that makes employers cover the cost of doing your job can require them to repay your defense of a civil lawsuit over work you did in your job, but it is not a duty to defend you, and it ends once you believed the order was unlawful. No case we found says it pays for a criminal lawyer.

    Red flag: help with legal fees that comes with "stick to the story." The Justice Department says fees "advanced on the condition that an employee adhere to a version of the facts that the corporation and the employee knew to be false" can be obstruction.

    Justice Manual 9-28.730; Cal. Labor Code § 2802; Cassady v. Morgan, Lewis & Bockius, 145 Cal.App.4th 220 (2006); Los Angeles Police Protective League v. City of Los Angeles, 27 Cal.App.4th 168 (1994)

In an investigation, the company's lawyers have one client. It isn't you.

The long tail

It can come back ten years later

In plain words Fraud cases are slow. The job you leave this year can call you in ten.

  1. Amerigroup Illinois 1998–2008 · 10 yrs

    Whistleblower sued 2002 · jury verdict 2006 · settled $225M, 2008

  2. WellCare 2002–2016 · 14 yrs

    Whistleblower sued 2006 · raid 2007 · convictions 2013 · upheld on appeal 2016

  3. Kaiser Permanente 2009–2026 · 17 yrs

    Whistleblowers sued 2013 · DOJ joined 2021 · settled $556M, 2026

  4. Independent Health 2011–2024 · 13 yrs

    Whistleblower sued 2012 · DOJ joined 2021 · settled up to $98M, 2024

  5. Cigna 2012–2023 · 11 yrs

    Whistleblower sued 2017 · DOJ joined 2022 · settled $172M, 2023

  6. Centene, Medi‑Cal pharmacy 2017–2023 · 6 yrs

    California Attorney General settlement, $215M, 2023

From the first year of conduct the government described to the final resolution. Five of these six took ten years or more. The settlements were without admission of liability, except that Cigna admitted specified conduct in a $37 million part of its settlement. WellCare's bar ends with executives' criminal convictions, upheld in 2016 and pardoned in 2021.

Up to 10 yrs

How long after a violation a False Claims Act case can still be filed: usually 6 years, or 3 years after the government learns of it, but never more than 10 (31 U.S.C. § 3731(b)).

5 yrs

The usual limit for a federal crime (18 U.S.C. § 3282). For a conspiracy, it runs from the last act, not the first.

10 yrs

How long Medicare plans must keep proof that each employee was trained, under CMS's compliance guidelines.

Exclusion: the career ban

A conviction tied to Medicare or Medicaid means mandatory for at least five years. An excluded person can't be paid by those programs for anything, including "administrative and management services," and the federal inspector general names managed care plans in its guidance. Medicaid plans may not keep excluded people in work that matters to their state contract. The 2021 pardons did not take most of the WellCare executives off the list: four of the five were still excluded in October 2026.

42 U.S.C. § 1320a-7(a), (c)(3)(B); HHS-OIG Special Advisory Bulletin on the Effect of Exclusion (May 8, 2013); 42 CFR § 438.610; HHS-OIG List of Excluded Individuals/Entities, October 2026

Licenses

California's nursing board can discipline a registered nurse for a felony conviction, or one "substantially related" to nursing. For physicians, "knowingly making or signing" a false document related to medicine is unprofessional conduct. California's licensing boards can act on a related conviction.

Cal. Bus. & Prof. Code §§ 2761(e), 2261, 490

Time doesn't wash it out

Practice Fusion's sales executive dealt with Purdue Pharma in 2015 and 2016. In late 2019, knowing the Justice Department was investigating, he deleted files. He pleaded guilty in 2021 and was sentenced in 2024. Kaiser's case ran 17 years from the first alleged conduct to settlement.

U.S. Attorney, District of Vermont, Mar. 8, 2021 and May 13, 2024; DOJ, Jan. 14, 2026

The record of what you did today will outlast the manager who asked you to do it.

What to do

The safe way out

In plain words The earlier you act, the more choices you have.

  1. Don't do it. Ask for it in writing.

    California law doesn't require you to follow an unlawful order, and it bars retaliation for "refusing to participate in an activity that would result in a violation" of law. That protection is for refusing something that really would break the law, so get advice early. A short, calm email works: "I want to be sure I do this right. Can you send me the instruction in writing?"

    Cal. Labor Code §§ 2856, 1102.5(c), 1102.6

  2. Write it down tonight

    Who asked, when, what they said, and which members, claims, letters or reports it touched. Your own words, dated, kept off company systems. Your notes, not member records.

    Your lawyer decides what to keep and how

  3. Never delete. Never "clean up."

    Once you think an investigation is possible, deleting or editing a record to affect it is a crime, even a record that would have helped you. Keep everything as it is.

    18 U.S.C. § 1519

  4. In any interview: your own lawyer, then the truth

    You can ask for time to talk to your own lawyer before you answer. What you can never do is shade the truth. A WellCare vice president was convicted for what he said in his interview, not for the fraud.

    18 U.S.C. § 1001

  5. Get your own lawyer first

    A whistleblower lawyer if you want to report; many work on contingency. A defense lawyer if you did something you're worried about. Either way, not the company's lawyer.

    See "Inside the plan" for how reporting works

  6. Earlier is safer

    If you only keyed in what you were told, the Justice Department's rules can treat you as a "minimal participant" who is still eligible for an award. Anyone who "meaningfully participated" gets no award. A person who reports first, before anyone asks, and discloses their own role can sometimes get a non-prosecution agreement. That door closes once investigators contact you.

    DOJ Corporate Whistleblower Awards guidance § II.1.e & n.4; Criminal Division Pilot Program on Voluntary Self-Disclosures for Individuals (2024)

A fair word

Most people at a plan will never be a target. The Justice Department says it prioritizes "senior-level personnel or other culpable actors," and charges are not convictions: the HealthSun director was acquitted. This page isn't here to scare you. It's here so you are never the easiest name in someone else's case.

Inside the plan: how to come forward safely → Get the desk card

NoSuchProvider.org · desk card

If you're asked to do something that feels wrong

  1. Pause. "Can you send me that in writing?"
  2. Write it down tonight. Who, when, what, which records.
  3. Don't delete anything. Don't change any dates.
  4. Get your own lawyer before any interview.
  5. Never lie to anyone investigating.

The order disappears. Your login doesn't. · nosuchprovider.org/health-plan-employee-liability.html · General information, not legal advice.

Questions employees ask

Your questions, answered plainly

Can I be held personally liable for fraud my health plan committed?

Yes, but only for what you did and what you knew. The False Claims Act reaches "any person" who knowingly causes a false claim, and criminal fraud laws reach individuals too. If you truly didn't know something was false, you are generally treated as the tool. If you knew, or made sure not to know, you can be liable yourself, even when the company also pays.

More: Didn't know, looked away, or knew

Is "my manager told me to" a defense?

No. Following orders doesn't excuse something you knew was illegal. The manager can be guilty too, because the law covers anyone who "willfully causes" an illegal act. But the order usually isn't written down, and your login is. The big plans' codes of conduct also tell you to report any request to break the law, not to follow it.

More: Felonies in disguise

Can I get in trouble for fraud I didn't know about?

Generally not for a crime: criminal fraud requires that you knew, and being careless or foolish isn't knowing. Two warnings. If you suspected and deliberately avoided finding out, courts treat that "willful blindness" as knowing. And in a civil False Claims Act case, "reckless disregard" counts, with "no proof of specific intent to defraud."

More: The three zones

My employee ID is on every action. If I did it because I was told to, whose fault is it on paper?

On paper, yours, until someone shows otherwise. Systems usually record who did what and when. They don't record who asked. That is why writing down the instruction matters: who, when, what, and which records. A dated note made at the time is what turns "the system shows you did it" into "my manager told me to, and here's when."

More: How a company does fraud with your hands

What should I do if my manager asks me to do something I think is wrong?

Don't do it yet. Ask for the instruction in writing, write down what was said, and talk to your own lawyer or report it. In California an employer may not retaliate against you "for refusing to participate in an activity that would result in a violation" of a law or regulation. That covers refusing something that really would break the law, so get advice early.

More: The safe way out

My manager only says it on calls or in chat. Why does that matter?

Because the spoken order disappears and your work doesn't. A call leaves no record of what was said, and a chat may be set to delete itself. The letter you held, the code you added or the call you logged stays in the system under your name. The Justice Department now grades companies on whether they can recover disappearing messages.

More: "Let's take this to Signal"

Compliance or Legal wants to interview me. Do I need my own lawyer?

If you're worried about anything you did or saw, talk to your own lawyer first. The company's lawyers represent the company. What you tell them is protected by a privilege that belongs to the company, which can choose to share it with the government. You can ask for time to get advice. Codes require cooperation, so ask; don't just refuse.

More: When investigators come

What is an Upjohn warning?

It is what company lawyers say at the start of an interview so you know they don't work for you. One version, quoted by a federal appeals court: "We represent the company. These conversations are privileged, but the privilege belongs to the company and the company decides whether to waive it." In plain words, your words can end up with prosecutors.

More: The interview

Does the company lawyer represent me? Is what I say confidential?

No, and only partly. The lawyer represents the company. Your conversation is kept from outsiders, but the company controls that and can give it up. Even if it doesn't, to earn credit with prosecutors it must hand over the relevant facts it learned in its interviews, including yours.

More: When investigators come

Will my company give what I say to the government?

It may, if it wants the best deal. Since March 2026, the Justice Department's corporate policy says full cooperation means disclosing facts about all individuals involved "regardless of their position, status, or seniority," with "attribution of facts to specific sources," and making employees available for interviews.

More: The company trades facts for credit

Do I have to cooperate with the internal investigation?

Your job may depend on it. Every code we read requires cooperation, and UnitedHealth's says failing to cooperate "is itself a violation of Company policy." Cooperating doesn't mean doing it alone: you can ask to speak to your own lawyer first, and you must never lie. A company that uses a confidentiality agreement to stop you from talking to the Justice Department risks being treated as obstructing.

More: What you agreed to

Is it illegal to delete work messages if there might be an investigation?

It can be a serious crime. Federal law makes it a felony, up to 20 years, to delete, alter or hide a record to affect a federal investigation, including one that is only being contemplated. Deleting a chat because a manager asked puts your name on that act. Once you think an investigation is possible, keep everything.

More: "Delete that chat"

Can my employer see my Teams messages, even deleted ones?

Assume yes. Companies can set their systems to keep copies of work chats after you delete them, and the Justice Department grades companies on whether they can recover messages, including from personal phones. Elevance's code says it can access "any personal device used for company business" and release what it finds "to government agencies." Deleted doesn't mean gone.

More: What you agreed to

Is it illegal to backdate or change a letter or record?

It can be. Knowingly and willfully falsifying a material fact in a health plan matter is a federal crime, and so is altering a record to obstruct an investigation. For member notices it matters even more: a Medicaid member's 60 days to appeal are counted from the date printed on the notice. A false date can take days from someone's appeal.

More: The letter that only exists in the computer

Can I be fired for reporting fraud or refusing to take part?

Not lawfully, though the protections have conditions and deadlines. Federal law protects employees who act to stop False Claims Act violations, with remedies including reinstatement and double back pay. California protects you for reporting what you reasonably believe is a violation to a government agency or a supervisor, and for refusing to take part in something that would break the law. If you show your report was a contributing factor in how you were treated, the employer must prove by clear and convincing evidence it would have done the same thing anyway. Talk to an employment lawyer soon.

More: Know your protections by name

Can I report anonymously? Can I still report if I took part?

Often yes to both, with limits. The Justice Department's corporate whistleblower program accepts anonymous tips if you have a lawyer. Someone who "meaningfully participated" can't get that award, but a "minimal participant" can. In a False Claims Act case, a court can reduce the share of anyone who "planned and initiated" the fraud, and someone convicted for their role gets no share at all. A False Claims Act suit starts under seal, but the seal is temporary. Talk to a lawyer before you do anything.

More: Earlier is safer

How far back can investigators go?

Further than most people think. A False Claims Act case can be filed up to 10 years after the violation. Most federal crimes have a five-year limit, but for a conspiracy it runs from the last act. In the six plan cases on this page, five took ten years or more from the first conduct to the end.

More: It can come back ten years later

What is OIG exclusion, and can I still work in health care?

It is a federal ban from Medicare, Medicaid and other federal health programs. A conviction tied to those programs means at least five years. While excluded, you can't be paid by those programs for any work, including office and management jobs at a managed care plan, and Medicaid plans may not keep you in work that matters to their state contract. Most health care employers rely on that money.

More: Exclusion: the career ban

Can I lose my nursing or medical license?

Yes. California's nursing board can discipline a registered nurse for a felony conviction, or any conviction substantially related to nursing. For physicians, "knowingly making or signing" a document related to medicine that "falsely represents the existence or nonexistence of a state of facts" is unprofessional conduct. Signing a denial you know misstates the facts, or misstates that you reviewed the case, is the kind of document that law covers.

More: "Just sign the batch"

Does my yearly fraud, waste and abuse training matter if there's an investigation?

Yes. It is part of how a company shows it told you the rules. Medicaid plans must train their employees on federal and state requirements, and Medicare plans must be able to prove each employee was trained and keep those records for 10 years. Molina's code requires employees to acknowledge it "when they are hired and annually thereafter." That record makes it harder to say no one told you the rules.

More: What you agreed to

Sources

Every claim on this page, and where it came from

  1. Codes of conduct. Centene Corporation, 2026 Code of Conduct: A Guide to Doing What's Right, pp. 7, 8, 10, 11, 13, 14, 18, 28; Elevance Health, Code of Conduct, January 2026, pp. 5, 6, 9, 16 (printed page numbers); Molina Healthcare, Code of Business Conduct and Ethics, as amended July 8, 2025, pp. 4, 7, 8, 19; UnitedHealth Group, Code of Conduct: Our Principles of Ethics & Integrity, December 2025, pp. 6, 13.
  2. Health Net Community Solutions, Medi-Cal Compliance Program Description 2026, pp. 8, 22.
  3. Indemnification. Centene certificate of incorporation (Art. Seventh) and by-laws (Art. VIII); Elevance Health Amended and Restated Articles of Incorporation § 7.9 (as amended June 27, 2022); Molina Healthcare bylaws § 9.8(a)–(b), (f) (restated May 6, 2026); 8 Del. C. § 145.
  4. Federal law. 45 CFR § 164.312(a)(2)(i), (b) (unique user IDs and audit controls in systems that hold health information); 18 U.S.C. §§ 2(b), 1001, 1035, 1347, 1519, 3282; 31 U.S.C. §§ 3729(a)(1), 3729(b)(1), 3730(b)(2), 3730(b)(5), 3730(d)(3), 3730(h), 3731(b); 42 U.S.C. § 1320a-7(a), (c)(3)(B); 42 CFR §§ 431.211, 438.208, 438.210(d), 438.400, 438.402(c)(2)(ii), 438.404, 438.416, 438.608, 438.610.
  5. California law. Labor Code §§ 1102.5(b)–(c), 1102.6, 2802(a), 2856; Business & Professions Code §§ 490, 2261, 2761(e); SB 1120 (Stats. 2024, ch. 879), amending Health & Safety Code § 1367.01; Welfare & Institutions Code § 10950 and following; Cassady v. Morgan, Lewis & Bockius LLP, 145 Cal.App.4th 220 (2006).
  6. Court decisions. United States v. Giles, 300 U.S. 41 (1937); Global-Tech Appliances, Inc. v. SEB S.A., 563 U.S. 754 (2011); In re Grand Jury Subpoena: Under Seal, 415 F.3d 333 (4th Cir. 2005); United States v. Clay, 832 F.3d 1259 (11th Cir. 2016); Ninth Circuit Manual of Model Criminal Jury Instructions (deliberate ignorance).
  7. Justice Department policy. Corporate Enforcement and Voluntary Self-Disclosure Policy (Deputy Attorney General, Mar. 10, 2026), App. B; Justice Manual 9-28.700, 9-28.720 n.2, 9-28.730 and 4-4.112; Criminal Division, "Focus, Fairness, and Efficiency in the Fight Against White-Collar Crime" (May 12, 2025); Evaluation of Corporate Compliance Programs (Sept. 2024); Corporate Whistleblower Awards Pilot Program guidance (rev. July 30, 2026), §§ II.1.e & n.4, II.2.d, IV.2, IV.4–5; Pilot Program on Voluntary Self-Disclosures for Individuals (Apr. 15, 2024).
  8. WellCare. Deferred prosecution agreement, May 5, 2009, ¶¶ 9.A, 20.A (filed as WellCare Form 8-K Ex. 10.1); U.S. Attorney, M.D. Fla., releases of Mar. 2, 2011, June 10, 2013, May 19, 2014, June 26, 2017; United States v. Clay (11th Cir. 2016); DOJ Office of the Pardon Attorney, pardons granted Jan. 2021; White House statement, Jan. 20, 2021.
  9. HealthSun. U.S. Department of Justice, release of Oct. 26, 2023, with the update of June 13, 2025 (acquittal).
  10. Notices. HHS-OIG, A-06-24-02000 (Louisiana Healthcare Connections, Mar. 30, 2026) and A-09-24-02007 (Health Share of Oregon, Aug. 13, 2026); CMS civil money penalty letter to Bravo Health, Nov. 10, 2009; CMS civil money penalty letter to Point32Health, Apr. 1, 2025; CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).
  11. Care management. New York Attorney General, RiverSpring settlement, May 23, 2024 (stipulation of May 16, 2024, S.D.N.Y. No. 17-cv-636).
  12. Grievances. California Department of Managed Health Care, Anthem Blue Cross penalty, Jan. 30, 2026.
  13. Clinical review. STAT News, "UnitedHealth pushed employees to follow an algorithm to cut off Medicare patients' rehab care," Nov. 14, 2023; Estate of Lokken v. UnitedHealth Group, No. 0:23-cv-03514 (D. Minn.), order of Mar. 9, 2026; ProPublica and The Capitol Forum, "How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them," Mar. 25, 2023; California Department of Insurance, SB 1120 guidance, May 5, 2025.
  14. Coding. U.S. Department of Justice, Kaiser Permanente affiliates settlement, Jan. 14, 2026; Cigna stipulation, U.S. ex rel. Cutler, M.D. Tenn. No. 3:21-cv-00748 (Sept. 29, 2023); CMS, Notice of Imposition of Intermediate Sanctions to Elevance Health, Feb. 27, 2026; Healthcare Dive, Apr. 1, 2026 (Elevance's response); U.S. Department of Justice, Independent Health settlement, Dec. 20, 2024; Cigna settlement, Sept. 30, 2023.
  15. Enrollment and sales. U.S. ex rel. Tyson v. Amerigroup Illinois, No. 02 C 6074 (N.D. Ill.): DOJ release, Oct. 31, 2006; judgment, Mar. 13, 2007; settlement, Aug. 2008; Chicago Tribune, Oct. 31, 2006. U.S. ex rel. Shea v. eHealth, Inc., No. 1:21-cv-11777 (D. Mass.), complaint in partial intervention, May 1, 2025, ¶¶ 326, 585.
  16. Other cases. United States v. Local Initiative Health Authority for Inland Empire Health Plan, C.D. Cal. No. 5:25-cv-02444 (filed Sept. 17, 2025), allegations only; HHS-OIG, naviHealth data brief OEI-09-24-00331 (June 8, 2026); Elevance Health Form 10-Q for the quarter ended Sept. 30, 2026 (CMS payment and July 13, 2026 CMS letter); HHS-OIG List of Excluded Individuals/Entities (LEIE), October 2026 update; U.S. Department of Justice, Freedom Health and Optimum HealthCare settlement, May 30, 2017; People v. Health Net, stipulation and final judgment with permanent injunction, 2025, without admission; U.S. Attorney, D. Vt., Practice Fusion releases of Mar. 8, 2021 and May 13, 2024; California Attorney General, Centene settlement, Feb. 8, 2023.
  17. Deleted chats. Microsoft Learn, "Learn about retention for Microsoft Teams" (retention policies keep copies of deleted Teams messages for eDiscovery).
  18. Exclusion and training. HHS-OIG, Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs, May 8, 2013; CMS Medicare Managed Care Manual ch. 21 and Prescription Drug Benefit Manual ch. 9, §§ 50.3.1–50.3.2.

Where a company denied wrongdoing or settled without admitting liability, this page says so. Allegations are not findings. Quotations from codes of conduct are exact and link to each company's own document. This page is general information, not legal advice. If you represent an organization named here and believe something is inaccurate, request a correction.