A strong Pennsylvania woman built the machine and blew the whistle, resulting in a $22.5 million Medicare Advantage settlement
By Jeffrey Newman, Esq., MBA, with help from AI
There is a set of stone steps on the east face of the Philadelphia Museum of Art that visitors still run up with their arms in the air. The man they are imitating never existed. Rocky Balboa was a movie boxer, a club fighter nobody expected to last a single round. But he did last, by sheer guts, and Philadelphia adopted him. The city saw itself in him. They don’t quit.
This fall, a strong Pennsylvania woman went the distance. Her name is Suzanne Crawford.
On September 30, 2026, the U.S. Attorney’s Office for the Eastern District of Pennsylvania announced that Independence Blue Cross — IBX, Philadelphia’s largest Medicare Advantage insurer — had agreed to pay $22.5 million to resolve allegations that it submitted, and failed to withdraw, inaccurate diagnosis codes in order to collect more from Medicare. IBX denies the allegations, and the settlement is not an admission of liability.
That tells the story of the case. It does not tell the story of the woman who helped build the IBX system. The case was filed almost six years earlier, under seal, by the whistleblower who helped construct that system. She came forward, retained counsel, and advanced the case.
How Medicare Advantage pays companies
Medicare Advantage is a private alternative to traditional Medicare. Instead of paying doctors visit by visit, the government pays an insurer a fixed monthly amount for each enrollee, and the insurer covers that person’s care.
The monthly amount is not the same for everyone. Sicker patients cost more, so Medicare pays Medicare Advantage companies more for those people. To measure how sick each patient is, Medicare relies on the diagnosis codes insurers submit. More serious diagnosis codes produce a higher risk score, and a higher risk score produces a larger payment to the company.
The incentive is plain. Every diagnosis the insurer submits can mean more money.
The system assumes honesty. Insurers must certify every year that their diagnosis data is accurate, complete and truthful. And Medicare’s submission system has a built-in way to take a bad code back — a delete indicator, in the language of Ms. Crawford’s complaint.
One-way chart review
For services from 2016 through 2020, according to the government, IBX ran a chart review program called IBX Review. The company pulled patients’ records from their doctors and had nurses read them, looking for every condition the records supported.
When the nurses found conditions the doctors had not reported, IBX sent the new codes to Medicare and, in some instances, was paid more for those patients.
But the same reviews also turned up the reverse: diagnoses the doctors had reported that the nurses could not find in the records. The government contends that IBX did not investigate or withdraw all of those unsupported codes — which would have meant paying money back — and then certified to Medicare that its data was accurate.
Lawyers call this a one-way chart review. The search runs in one direction only: toward more money.
Of the $22.5 million, the settlement designates $11.25 million as restitution. Ms. Crawford will receive $3,825,000 — about 17 percent of the total.
The woman who wrote the code
The settlement agreement says little about Ms. Crawford. Her complaint, filed November 18, 2020, says more.
She worked at IBX from September 2013 to November 2016 in its informatics department, rising from analyst to manager to Director of Risk Adjustment Business Processes. By her account, she helped develop and manage the company’s chart review programs. The application the IBX Review nurses used to read charts and enter new codes was, the complaint says, developed and maintained by her team. She oversaw the software that chose which patients’ charts to pull.
She knew the machine from the inside because she had helped build it.
What she did not do, by her own account, was recognize it as fraud while she was there. The complaint says she came to understand the one-sided nature of the programs after she left IBX and went to work for another Medicare Advantage insurer.
That is worth noting. She was not a lone dissenter in a conference room. She was a professional who built what she was asked to build, left, saw elsewhere how the work could be done, and looked back clearly and honestly at her own. Then she retained counsel, led in Philadelphia by Peter H. LeVan, Jr., who filed the case on her behalf. Then they waited approximately six years for the government to finish its investigation and its work.
What she alleged, and what was settled
Her complaint described three programs, not one:
- CARA, run by the outside vendor Inovalon, which the complaint says IBX Review replaced in 2016;
- IBX Review itself;
- an EMR Data Exchange Program, in which IBX allegedly took diagnosis codes from electronic records supplied by health systems and converted them directly into Medicare submissions without confirming the patient still had the condition.
The complaint alleged that in 2015 IBX spent $6 million on CARA’s Medicare work and took in $23.1 million in Medicare revenue from it, a return of 3.85 to 1. It alleged that IBX’s own sample audits found inaccuracy rates of 10 to 15 percent, and that when an audit caught a bad code, IBX deleted it. What the company did not do, she alleged, was the simple thing: compare its chart review results against the codes it had already submitted and delete the ones the review could not support. She estimated that the one-sided programs brought in $20 million or more a year.
These are allegations. None was proven in court, and IBX denies them.
The settlement covers only IBX Review, for payment years 2017 through 2021 — a period that runs mostly after Ms. Crawford left. The documents do not say why CARA, the EMR program and the earlier years were left out. The agreement does preserve the government’s other claims: the dismissal is without prejudice as to anything beyond the settled conduct.
IBX told The Philadelphia Inquirer that the matter was not about the quality of care its members received but about differing views of documentation and reporting requirements, and that many major health plans have faced similar scrutiny.
Philadelphia, twice in one year
IBX was not the first.
Six months earlier, on March 11, 2026, Aetna — a national insurer incorporated in Pennsylvania — agreed to pay $117.7 million to resolve similar allegations. The government contended that Aetna’s 2015 chart review program added codes when reviews supported them and ignored the reviews when they showed Aetna had been overpaid. A second part of the settlement concerned morbid obesity codes for patients whose recorded body mass index did not fit the diagnosis. That part came from a whistleblower case filed in the Eastern District of Pennsylvania by a former Aetna risk-adjustment coding auditor, who will receive $2,012,500. Aetna did not admit liability.
The same theory. The same federal district. And one of the same prosecutors: Assistant U.S. Attorney Peter Carr worked on both.
Nor did it start with Aetna. In September 2023, Cigna agreed to pay $172.3 million to resolve allegations that included a one-way review program for payment years 2014 through 2019 and unsupported morbid obesity codes. The Eastern District of Pennsylvania handled those parts of the case. A separate part, concerning diagnoses based on in-home assessments, came from a whistleblower, a former part-owner of a home-visit vendor, and was handled in New York and Tennessee. Cigna did not admit liability.
When the Cigna settlement was announced, U.S. Attorney Jacqueline C. Romero said her office had “prioritized combating Medicare Advantage fraud, including applying data-driven investigative methods.” The office’s civil chief, Gregory David, is named in all three matters — Cigna, Aetna and IBX.
I have found no announcement of a dedicated Medicare Advantage unit. But the office said three years ago that this fraud was a priority, and the region’s largest Medicare Advantage insurer and another major one have now paid to resolve one-way chart review allegations in the same courthouse in the same year.
Across the country
The Philadelphia cases sit inside a national pattern.
| When | Who | Amount | What was alleged | Who brought it |
| 2023 | Martin’s Point (Maine) | $22.485M | Chart reviews that added unsupported codes | Former risk-adjustment manager |
| Sept. 2023 | Cigna (E.D. Pa., S.D.N.Y., M.D. Tenn.) | $172.3M | One-way chart review; in-home assessments; obesity codes | Former co-owner of a home-visit vendor (home-visit claims) |
| Jan. 2026 | Kaiser Permanente affiliates | $556M | Invalid diagnosis codes | Six whistleblowers, incl. former employees |
| Mar. 2026 | Aetna (E.D. Pa.) | $117.7M | One-way chart review; morbid obesity codes | Former coding auditor (obesity case) |
| Aug. 2026 | The Villages Health (Fla.) | $541.5M | False diagnosis codes (provider group) | Self-disclosed by the company |
| Sept. 2026 | Independence Blue Cross (E.D. Pa.) | $22.5M | One-way chart review | Former risk adjustment director |
Four things stand out.
- The dollars are growing. Kaiser’s $556 million in January is the largest Medicare Advantage risk-adjustment settlement on record.
- Insiders bring most of these cases. Behind Martin’s Point, Kaiser, Aetna and IBX were people inside coding and risk-adjustment operations — the people who see the data.
- Not every case starts with a whistleblower. The Villages Health reported its own problem to the government, which credited the disclosure.
- The money at stake is enormous. MedPAC, Congress’s Medicare advisory commission, estimates the government will pay about 14 percent more — some $76 billion — for Medicare Advantage enrollees in 2026 than it would have for the same people in traditional Medicare, driven largely by favorable selection and coding intensity.
Fraud, or coding? An honest caveat
That $76 billion is not a fraud figure, and it should not be read as one.
Coding intensity means Medicare Advantage plans record more diagnoses than traditional Medicare does. Some of that is lawful. If the codes genuinely reflect conditions the patients have, as documented in their records for that year, they may be legitimate. But if a condition documented years earlier is carried forward and submitted when the current record does not support it, that is not legitimate.
What the settlements reveal is more telling: a recurring allegation, raised by insiders and pressed by the government against plans large and small, that the search for diagnoses ran only one way. As Ms. Crawford’s complaint alleges, a simple comparison algorithm would have caught the unsupported codes — and IBX made no effort to build one.
What it adds up to
A settlement is not a verdict. Every agreement discussed here says so plainly. But a pattern of settlements is a pattern, and liability under the False Claims Act requires proof that a defendant acted knowingly.
Across the country, and twice in Philadelphia in a single year, health plans have paid to resolve allegations that a system built to find diagnoses never checked for the wrong ones. And in case after case, the first person to say so was someone who worked inside the system.
Congress built the False Claims Act to rely on such people to protect the country from fraud. The government offers them a share of what it recovers precisely because they can see what auditors cannot.
These people are courageous. Suzanne Crawford helped build the machine, came to see — as she alleged — how it was being misused, and went the distance.
Jeff Newman Law is a national whistleblower law firm that handles whistleblower cases under the False Claims Act, including healthcare and tariff fraud matters and other kinds of cases. Reach the firm at www.jeffnewmanlaw.com or 617-823-3217.
Sources
- U.S. Attorney’s Office, E.D. Pa., Independence Blue Cross settlement release (Sept. 30, 2026): https://www.justice.gov/usao-edpa/pr/independence-blue-cross-agrees-pay-225-million-resolve-allegations-it-violated-false
- Settlement Agreement, United States ex rel. Crawford v. Independence Blue Cross (signed Sept. 11–14, 2026): https://www.justice.gov/opa/media/1463421/dl
- Complaint, United States ex rel. Crawford v. Independence Blue Cross, No. 2:20-cv-05818 (E.D. Pa. filed Nov. 18, 2020), Doc. 1
- Harold Brubaker, “Independence Blue Cross settled a Medicare Advantage false claims suit for $22.5 million,” The Philadelphia Inquirer (Sept. 30, 2026): https://www.inquirer.com/health/ibx-false-claims-settlement-medicare-advantage-20260930.html
- U.S. Department of Justice, Aetna settlement release (Mar. 11, 2026): https://www.justice.gov/opa/pr/aetna-agrees-pay-1177-million-resolve-false-claims-act-allegations
- U.S. Department of Justice, Kaiser Permanente affiliates settlement release (Jan. 14, 2026): https://www.justice.gov/opa/pr/kaiser-permanente-affiliates-pay-556m-resolve-false-claims-act-allegations
- KFF Health News, Kaiser settlement and six whistleblowers: https://kffhealthnews.org/news/article/medicare-advantage-record-fraud-settlement-kaiser-permanente-556-million/
- U.S. Department of Justice, The Villages Health System settlement release (Aug. 26, 2026): https://www.justice.gov/opa/pr/villages-health-system-llc-agrees-5415m-settlement-resolve-false-claims-act-allegations
- U.S. Department of Justice, Martin’s Point Health Care settlement release (2023): https://justice.gov/opa/pr/martins-point-health-care-inc-pay-22485000-resolve-false-claims-act-allegations
- U.S. Department of Justice, Cigna Group settlement release (Sept. 30, 2023): https://www.justice.gov/archives/opa/pr/cigna-group-pay-172-million-resolve-false-claims-act-allegations
- MedPAC, March 2026 Report to the Congress, press release (Mar. 12, 2026): https://www.medpac.gov/wp-content/uploads/2026/03/March_2026_MedPAC_Report_Press_Release_SEC.pdf
