On October 22, 2026, the Department of Justice’s Civil Division and the Department of Health and Human Services announced a six-month pilot program that changes the calculus for any organization that discovers its own coding or billing errors before the government does. The Healthcare False Claims Act Self-Disclosure Pilot Program (“FCA SDPP”) offers a defined repayment range and a coordinated civil release to companies that come forward about conduct the government doesn’t already know about — a direct answer to the question coding compliance teams ask every time an internal audit turns up a problem: report it, or hope it stays quiet.
What the Pilot Actually Does
DOJ says the program is meant to free up government resources to focus on “recalcitrant actors,” while giving cooperative organizations a faster, more predictable path to resolution. In exchange for a disclosure, the company receives a coordinated civil release with no factual admissions, and coverage extends to specific HHS administrative authorities: Medicare enrollment revocation under 42 C.F.R. § 424.535, and permissive exclusion under 42 C.F.R. §§ 1001.901 and 1001.951. HHS-OIG has also agreed not to require a Corporate Integrity Agreement for pilot participants, and CMS will not impose civil monetary penalties or seek revocation on its own separate track.
Eligibility is broad on paper: providers, suppliers, manufacturers, payors, and related entities whose products or services are paid for, directly or indirectly, with federal health care program dollars. The catch is the same one that has always separated voluntary disclosure from damage control — the conduct has to be “previously unknown” to the government. If DOJ or CMS already has it on their radar, through a RADV audit, a whistleblower, or routine data-mining, the company can still seek ordinary cooperation credit under Justice Manual Section 4-4.112, but it no longer qualifies for a pilot resolution.
The Repayment Multiplier, Explained
Despite the “fixed” in some early coverage of the announcement, the program actually sets a range: repayment runs from 1.25 to 1.6 times what DOJ calls the “Base Self-Disclosure Repayment.” Where an organization lands in that range depends on several factors DOJ will weigh case by case.
How the Multiplier Range Gets Set
The analysis looks at how early the company came forward, how long and how widespread the conduct was, whether senior leadership was involved, what the company gained from the conduct, and whether the company inherited the issue through an acquisition and moved quickly to fix it. A six-month-old coding error caught and reported in week one looks very different, multiplier-wise, from a pattern that ran for three years before anyone flagged it.
Anti-Kickback Conduct Is Calculated Differently
For disclosures involving the Anti-Kickback Statute, DOJ is not basing the repayment on the full amount of claims paid — the measure the government typically pursues in AKS-based FCA cases. Instead, it looks at the remuneration involved, the revenue the conduct generated, and whether aggravating factors like patient harm are absent. That’s a meaningfully different exposure calculation for compliance teams weighing whether an arrangement tied to coding or billing incentives needs to go on the disclosure list.
Why This Matters for Coding Compliance, Specifically
Coding compliance teams are usually the first to see the kind of conduct this pilot is built for: a modifier applied incorrectly across a service line for a year, an HCC risk-adjustment pattern that drifted after a system change, a chart-review finding that was fixed going forward but never reconciled retroactively. Those are exactly the “previously unknown” errors the FCA SDPP is designed to catch before they become RADV extrapolations or qui tam filings. The pilot effectively prices in a reward for catching your own mistakes fast — and it prices in a penalty, in the form of losing eligibility altogether, for sitting on a finding.
That changes the internal math around automated coding audits and continuous claim monitoring. A compliance program that can surface a coding anomaly within days, quantify the affected claims, and route it to legal before an external audit or a whistleblower does has a real shot at the lower end of the 1.25x-1.6x range. One that relies on periodic manual chart review and finds the same issue eighteen months later is more likely to be looking at a RADV audit or a False Claims Act suit on someone else’s timeline, not its own.
The Clock Is the Real Constraint
Submissions under the FCA SDPP Protocol are due by 11:59 PM on April 22, 2027, and the protocol itself is detailed: a written description of the conduct and the legal requirements at issue, supporting documentation cross-referenced to that description, a description of corrective steps already taken, financial information sufficient for DOJ to calculate the Base Self-Disclosure Repayment, and a certification from an authorized representative. Compliance teams that want to use this window need the underlying coding and claims data organized well before the deadline, not assembled under pressure in April.
- Timestamp every audit finding. Because eligibility turns on “previously unknown,” the date a coding issue was first identified internally is now a load-bearing fact, not a footnote.
- Build the claims-level financial summary now. DOJ needs enough data to calculate the Base Self-Disclosure Repayment, and compiling that after a finding surfaces is slower than having claim-level detail already on hand.
- Triage FCA versus AKS exposure separately. The repayment math differs for Anti-Kickback-related conduct, so findings need to be sorted before they’re packaged for disclosure.
- Decide, in advance, who can certify a submission. The protocol requires a certification from an authorized representative — that authority should be assigned before a finding is sitting on someone’s desk.
- Calendar April 22, 2027 against your existing audit cycle. A finding that surfaces in March 2027 leaves very little runway to assemble a complete submission.
None of this works without visibility into coding patterns before an external auditor gets there first. That’s the problem Medikode’s automated medical coding platform is built to address — continuous, claim-level coding review that surfaces drift and anomalies early enough for compliance teams to act on their own timeline instead of the government’s.