A Step-By-Step Breakdown of a Medicare Fraud Case

August 8, 2023
Step by step guide to a Medicare fraud case

Medicare fraud is a prevalent issue causing substantial financial losses for taxpayers annually due to unscrupulous medical practitioners who either engage in outright fraudulent billing practices or are indifferent to the rules, but in either event they subordinate the better good of the taxpayers and sometimes the patients for their own profits. However, there is a way to combat the greed through the False Claims Act’s qui tam provisions which empower whistleblowers to report fraud and potentially earn a percentage of what the government recovers as a whistleblower award. By having a free confidential consultation with a whistleblower law firm and revealing inside information about Medicare fraud, you have the opportunity to know your rights and options and potentially blow the whistle to start on a path for a potential whistleblower reward and to hold entities accountable for their fraud.

A Step-By-Step Breakdown of a Medicare Fraud Case


Step 1: Understand Medicare Fraud and Abuse

Learn what constitutes Medicare fraud and abuse.  If you’re reporting Medicare Fraud you better make sure it’s actually fraud or against the regulations or else there’s little, if anything, that can be done. That’s why if you suspect fraud you should move on to Step 2.

Step 2: Choose a Whistleblower Law Firm

Select a reputable whistleblower law firm early to protect your rights and ensure you are credited as the original source of information. You should see if the firm works on a contingency basis? Are they asking you for funds upfront? Do they have experience in the type of case that you wish to bring?  All these questions and more you should ask when selecting the firm you wish to work with.

Step 3: Work with Your Whistleblower Attorney

Discuss your allegations and evidence with your attorney, who will guide you through the process and assess the strength of your case and chart out the path for it.  Make sure you don’t gather evidence on your own without speaking with your attorney.

Step 4: File a Whistleblower Complaint

Your attorney will draft and file the complaint detailing your allegations and evidence with the appropriate authorities. Before they do that they will closely work with you to make sure you’re on the same page as to what the case is about and the best whistleblower law firms like Brown, LLC will make sure you sign off on the accuracy of the complaint and once again give permission before they file your case for you. The case will be filed confidentially under seal which means the defendant healthcare practitioner will not know about it for some time. 

Step 5: Cooperate with the Investigation

Your qui tam law firm will prepare you for what is known as a relator interview, where the government will ask you questions about your case. It is an informal interview; however, you have an obligation to be truthful and the government will assess the accuracy of your information, how helpful and forthright you and your counsel are and your demeanor as a witness.

Step 6: Intervention vs. Non-Intervention

While the case is under seal the government will investigate the allegations and make a decision whether to intervene, which means to step in and litigate it themselves in which case you probably will never be deposed and the relator interview and ongoing cooperation is the extent of your participation or if they don’t intervene then you and your law firm will discuss the reasons for the government’s declination and if the government permits you to proceed whether it is advisable to do so which will create a substantially greater commitment for the law firm and you moving forward. 

Step 7: Potentially Receive a Whistleblower Award

If the government recovers funds, you may be eligible for a whistleblower award up to 30% of the amount recovered. Your attorney will help negotiate the award on your behalf and you will be judged on such criteria like how cooperative you were, how long you let the fraud pass before you reported it, and how efficient your counsel was which underscores the need for a whistleblower law firm with a track record of success

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Common Types of Medicare Fraud

Phantom Billing: Billing Medicare for services or equipment not provided, including claims for non-existent patients.

Billing for Services Not Medically Necessary: Submitting claims for unnecessary procedures or treatments for financial gain, potentially harming patients.

Upcoding: Fraudulently billing for more expensive services than actually provided or falsely diagnosing a condition as more serious than it actually was or the length of time an encounter took.

Unbundling: Illegally billing separately for services that should be bundled together.

Double Billing: Submitting multiple claims for the same medical service or equipment, resulting in Medicare paying twice for the same service. Sometimes re-using the same one time use product.

Off-Label Marketing: Marketing drugs or medical equipment for uses not approved by the FDA, potentially increasing sales and reimbursement.

Kickbacks and Self-Referrals: Payments or gifts in exchange for referrals or services or providing of items at a price below fair market value, prohibited by the Anti-Kickback Statute (AKS) in federal healthcare programs. Self-Referrals are when patients are directed to other entities owned by the health care provider without full disclosure.  Both kickbacks and self-referrals create an appearance of conflict and thus compromise the integrity of the referral. 

The Role of Whistleblowers in Exposing Medicare Fraud

Whistleblowers are critical in uncovering Medicare fraud, assisting in the discovery of fraudulent practices that cost taxpayers billions of dollars each year. Whistleblowers provide authorities with insider knowledge and evidence of fraudulent activities, allowing them to investigate and prosecute those involved in the fraud. Whistleblowers’ information is frequently critical in beginning investigations because they have firsthand knowledge of the fraud, but you should obviously consult with a whistleblower law firm before moving forward so you can understand the risks and rewards.  You don’t want to blow the whistle to only find out down the road that your case is not actionable

Legal Protections and Incentives for Medicare Fraud Whistleblowers

Medicare fraud whistleblowers play a crucial role in combating fraud and have the opportunity to receive significant financial whistleblower rewards, ranging from 15% to 30% of the total recovery. To be eligible for such a reward, having original information about the fraud and reporting it through a whistleblower law firm is essential. An ideal firm should possess experience in interacting with the Department of Justice, ensuring a seamless and effective process for whistleblowers.

However, reporting Medicare fraud can be intricate and exposes whistleblowers to potential retaliation from their employers. Thankfully, there are robust protections in place to protect whistleblowers. The False Claims Act and other laws provide strong protections, including reinstatement, back pay, and compensation for damages, to safeguard whistleblowers’ rights throughout the process. Inherently filing the case under seal allows secrecy for a period of time which protects the whistleblower. 

To navigate this complex journey with confidence, whistleblowers can seek assistance from experienced qui tam attorneys. These skilled lawyers offer guidance, support, and ensure the protection of the whistleblower’s identity and rights. A notable advantage under the False Claims Act is that whistleblowers have time to gather information while maintaining confidentiality, allowing them to build a solid case.

Real-Life Examples of Successfully Prosecuted Medicare Fraud Cases

In July 2023, an EHR technology vendor, agreed to pay $31 million to settle False Claims Act (FCA) allegations regarding Medicare fraud. The company allegedly misrepresented certain versions of its EHR software and provided unlawful remuneration to users to promote their software. The allegations include false certification and violations of the Anti-Kickback Statute.

The settlement also resolved claims brought under the qui tam or whistleblower provisions of the FCA by health care professionals who will receive  a $5,580,000 whistleblower reward

In another Medicare fraud whistleblower settlement, a healthcare & wellness center, settled with the United States and California for $3.825 million. The settlement resolves allegations that they submitted false claims to Medicare and Medicaid by paying kickbacks to physicians for patient referrals. The Anti-Kickback Statute prohibits such practices to ensure patient interests are prioritized over financial incentives. Alta Vista allegedly provided extravagant gifts and monthly stipends to induce physician referrals from 2009 to 2019. The settlement results from a whistleblower complaint filed in 2015 by a former accounting employee. The whistleblower stands to receive $581,094 as a whistleblower award for her share of the federal government’s recovery under the False Claims Act’s qui tam provisions.

Reporting Medicare fraud is critical in preserving the integrity of the program, preventing future fraud, protecting the taxpayer and most importantly protecting the patient. You can report suspected Medicare fraud to the appropriate government agencies; however, if you want to be eligible for a whistleblower award under the False Claims Act, you must file your claim with the assistance of a whistleblower law firm that has experience litigating Medicare fraud cases.

Brown, LLC’s whistleblower attorneys are committed to assisting people with inside knowledge of healthcare fraud, including Medicare fraud, and have recovered hundreds of millions of dollars for their clients; however, past results do not guarantee future success.