How to Report Medicare Fraud: A Comprehensive Guide for Whistleblowers

Medicare is a critical healthcare program that provides services to millions of Americans. Unfortunately, it’s also a program that is vulnerable to fraud and abuse, which can result in significant financial losses for taxpayers and compromised care for patients. As a result, it’s crucial that individuals who have inside knowledge of Medicare fraud and abuse come forward to report it the right way.

If you’re considering blowing the whistle on Medicare fraud or abuse, it’s important to understand your rights, protections, and potential rewards. In this guide, we’ll answer some of the most common questions about reporting Medicare fraud and abuse.

Can a Medicare Whistleblower Remain Anonymous?

Initially whistleblowers who report Medicare fraud and abuse are inherently anonymous, since if the information is filed pursuant to the False Claims Act, it will be filed confidentially under seal. and the wrongdoer won’t know you filed it, usually for many years. The False Claims Act provides strong protections for whistleblowers, including the ability to file a qui tam lawsuit under seal, which means the case will not be on the public record. This provides the added protection that the whistleblower’s identity is kept confidential during the initial investigation by the government, which can help to protect the whistleblower from retaliation or other negative consequences.

Blowing the whistle under the False Claims Act (“FCA”) requires the use of a False Claims Act attorney.  The FCA statute also provides for strong protections against retaliation, but the whistleblower law firm should counsel you about your rights and how the qui tam case may play out.  There are other ways to potentially protect anonymity, such as using a corporate entity to blow the whistle or a straw relator, but neither practice is encouraged.  Although they add an additional layer of security, they also add unnecessary complications and delay, and if the matter is truly litigated to conclusion, the identity may become disclosed at some point. Also, using a straw entity or corporation may have the government discount the value of the contribution of the plaintiff and reduce a potential whistleblower award. Thus, while anonymity can help protect whistleblowers, it may also limit the rewards they receive if their qui tam lawsuit is successful. However, whistleblowers who file qui tam lawsuits may still be eligible to receive a significant financial reward of up to 30% of what the government recovers.

How Do You Address Medicare Fraud?

The first step in addressing Medicare fraud is to recognize the signs of potential fraud or abuse. Some common signs of Medicare fraud include:

• Billing for services that were not provided
• Submitting claims for services that are not medically necessary
• Upcoding or unbundling services to obtain higher reimbursement rates
• Offering kickbacks or other incentives to patients or healthcare providers
• Using unlicensed healthcare providers or billing for services provided by unlicensed providers

If you suspect that Medicare fraud or abuse is occurring, it’s important to report it to the appropriate authorities. This may include the Department of Health and Human Services, the Office of Inspector General, or the Department of Justice. If you report it directly to the government you will not be eligible for a whistleblower reward through those mechanisms, so you may experience risks without any upsides such as the whistleblower reward. You should also consult with an attorney who handles False Claims Act litigation cases to explore your legal options. Some of the best whistleblower law firms, like Brown, LLC will offer free, confidential consultations in most instances and are generally only paid if they win your case.

What Is the Reward for Reporting Medicare Fraud?

Whistleblowers who report Medicare fraud or abuse may be eligible to receive a significant financial reward under the False Claims Act. If the qui tam lawsuit is successful, the whistleblower may receive a portion of the damages recovered by the government. This can range from 15% to 30% of the total recovery, depending on the circumstances of the case.

It’s worth noting that whistleblowers who file qui tam lawsuits may also be eligible for other types of compensation, such as lost wages or damages resulting from retaliation.  Every year for the last decade hundreds of millions of dollars have been awarded to whistleblowers who reported items like Medicare Fraud, Defense Contractor Fraud and Pharmaceutical Fraud the right way with the use of a qui tam attorney.

How Is Medicare Fraud Determined?

Medicare fraud investigations are typically conducted by the Department of Justice and other government agencies, such as the Office of Inspector General. These investigations may involve a variety of techniques, such as data analysis, interviews with witnesses, and undercover operations.

If Medicare fraud is suspected, either the government or a whistleblower with whistleblower counsel may file a civil lawsuit under the False Claims Act. The government may also pursue criminal charges against individuals or organizations that engage in fraudulent activity. The criminal charges surprisingly do not always assist in the resolution of the civil portion of the case for someone who files a claim under the False Claims Act and in fact, may slow things down.

Which of the Following Is an Example of Medicare Fraud?

Some common examples of Medicare fraud include:

• Billing for services that were not provided
• Submitting claims for services that are not medically necessary
• Upcoding or unbundling services to obtain higher reimbursement rates
• Offering kickbacks or other incentives to patients or healthcare providers
• Using unlicensed healthcare providers or billing for services provided by unlicensed providers

What Is Considered Medicare Abuse?

Medicare abuse is a related concept to Medicare fraud and depends on the interpretation of the term. According to CMS, “Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.” Medicare abuse occurs when healthcare providers engage in practices that are inconsistent with accepted medical practices.

What Is the Most Common Type of Medicare Abuse?

One of the most common types of Medicare abuse is billing for unnecessary services. This may involve providing services that are not medically necessary or providing multiple services when one would suffice. Other types of abuse may include upcoding, which involves billing for a more expensive service than was actually provided, or unbundling services, which involves billing for each component of a service separately instead of as a package. Read more about each type of Medicare abuse and fraud on our Healthcare Fraud page.