In the following exclusive Q&A with RISE, Relator “whistleblower” Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, reflects on the years leading up to the complaint, the coding red flags she observed, and her hope for how this historic settlement will shape improvements in health care industry behavior.
As RISE previously reported, Kaiser Permanente and several of its affiliates have agreed to pay $556 million to resolve allegations that the organization submitted invalid diagnosis codes to inflate payments under the Medicare Advantage (MA) program—the largest False Claims Act settlement ever involving Medicare Advantage risk adjustment fraud.
But what was not initially reported: The settlement also includes the first known resolution of a case alleging risk‑adjustment fraud in the Affordable Care Act (ACA) marketplace, stemming from accusations that Kaiser improperly boosted ACA risk scores to increase its share of insurance pool funds, according to Goldberg Kohn, the law firm that represented Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, and Victoria Hernandez, RHIA, CDIP, CCS, CCS-P in their claims.
Bryant and Hernandez were longtime senior health information management coding professionals at Kaiser whose responsibilities included risk-adjustment documentation and coding. They filed their False Claims Act complaint after Kaiser failed to address the practices at Kaiser that they had identified as allegedly inflating beneficiaries’ risk scores and increasing Medicare risk adjustment reimbursements, and shifting more ACA insurance pool funds to Kaiser, without clinical justification associated with ongoing issues surrounding clinical documentation and coding.
“Health care coding requires rigorous adherence to guidelines and established rules of accuracy and honesty coupled with specific and truthful documentation,” said Bryant, who served as the national director of the coding quality and education group for Kaiser Foundation Health Plan prior to her retirement in October of 2017, in the announcement. “No patient should be saddled with clinical documentation and diagnoses for conditions they don’t have, and our government programs should not be paying or distributing money based on false documentation and coding.”
Furthermore, she said financial pressure should never be allowed to override these basic principles. “We filed our complaint when our attempts, over many years, to fix these problems at Kaiser internally were met with silence or even hostility.”
Federal prosecutors later alleged that Kaiser pressured physicians to add diagnoses after patient visits—sometimes months or more than a year later—even when those diagnoses were not clinically relevant, a violation of Centers for Medicare & Medicaid Services (CMS) rules for both Medicare Advantage and ACA risk adjustment. Incentive structures within the organization allegedly tied financial bonuses to risk‑adjustment performance, further deepening concerns about systemic misalignment between documentation, coding integrity, and reimbursement.
The case underscores the growing scrutiny of risk‑adjustment operations across programs—and the critical role internal experts play in identifying and preventing fraud. It also reflects a moment of accountability at a time when CMS has intensified oversight of documentation accuracy and retrospective risk adjustment practices.
In the following exclusive Q&A with RISE, Bryant, reflects on the years leading up to the complaint, the clinical documentation and coding red flags she observed, and her hope for how this landmark settlement will shape industry behavior.
Bryant currently works part-time as an independent HIM coding and CDI consultant.
Q: You and Victoria Hernandez (who held various Kaiser positions from 1995-2015, including regional director auditing and coding at The Permanente Medical Group in Northern California, 2014-2015) raised concerns internally for years before filing the complaint. What did those early internal efforts look like?
Bryant: Per our complaint, we discussed the documentation and coding issues, questions and discrepancies internally with KP Regional Coding Leadership several times. We also went to KP National Coding Leadership and KP Coding Compliance.
Q: The press release from Goldberg Kohn mentioned your attempts were met with silence or even hostility. What kind of pushbacks did you encounter?
Bryant: A few examples include being instructed not to talk to external coding experts; being told not to write to AHA Coding Clinic anymore with coding questions—and that happened in front of revenue cycle and physician leaders; being excluded from specific query‑practice meetings after being invited; and even being told at a coding compliance audit meeting not to speak.
Q: Which coding practices or diagnosis categories were most commonly misused?
Bryant: There were many HCC diagnoses targeted. In our ACA Risk Adjustment diagnosis case specifically, malnutrition and ventilator dependence status were identified as being over-documented and over-coded.
Q: From a coder’s perspective, what were the biggest red flags that signaled systemic issues rather than isolated mistakes?
Bryant: After reviewing the Official Guidelines for Coding and Reporting, published AHA Coding Clinic information, also reviewing the responses to our inquiries we had received from Coding Clinic, and seeing the frequency of Medicare Advantage HCC and ACA HHS HCC diagnoses climbing, we knew there were significant issues, these were the biggest coding red flags.
Q: What personal or professional risks did you consider before deciding to come forward as a whistleblower?
Bryant: I believed and still believe that I had a moral, ethical, and professional responsibility to come forward and share what was happening. As a relator, I wanted to do the right thing and get the practices to stop.
Q: Why is accurate clinical documentation so important for patient care, not just reimbursement?
Bryant: We are a health care system that is very “code‑dependent,” and since coding comes directly from clinical documentation, accuracy and truthfulness is vital for decision-making, quality, research, public health, coverage, treatment, and more—not just financials.
Q: Do you believe this case will deter similar practices across the industry, or is more oversight needed?
Bryant: It is my sincere hope that yes, the case and settlement will deter organizations, hospitals, and physician practices from going down similar paths—and that oversight will gain greater attention and influence prevention.
Q: What advice do you have for other coding professionals under pressure to code improperly?
Bryant: Speak up first and foremost, and do not be afraid. Share official coding resources that support your position and report concerns to internal compliance leadership.
Q: Looking back, what has been the most challenging and most rewarding part of this experience?
Bryant: The legal system does not always move quickly, and during these years we also had COVID—so patience was required. The most rewarding part is having our case and story be told to a broader audience and now officially through the settlement efforts of excellent legal representation, so that others can learn and prevent similar issues in their workplaces from occurring.