How to Report Medicare Fraud and Abuse: A Step-by-Step Guide

As a Medicare fraud whistleblower, reporting Medicare fraud and abuse is not only the right thing to do but is also necessary to protect patients and the integrity of the Medicare program. However, the process of reporting Medicare fraud and abuse can be complex and intimidating, especially for those who are unfamiliar with the healthcare industry and the legal system. Reporting to the authorities can potentially bring justice but unless you report it the right way you may not be eligible for a whistleblower award. If you’re interested in obtaining a whistleblower award, you must use a qui tam law firm to file a False Claims Act case to remedy systemic Medicare fraud.  You are prohibited from filing a case by yourself pro se. 

A whistleblower law firm will work with you to present your case in the best way possible and make sure you’re prepared every step of the way. In this guide, we will provide a step-by-step approach to help you report Medicare fraud and abuse the right way. 

Step 1: Understand Medicare Fraud and Abuse

Before reporting Medicare fraud and abuse, it is essential to understand what constitutes Medicare fraud and abuse. Medicare fraud occurs when a healthcare provider or supplier intentionally submits false claims to Medicare for services or supplies that were never provided or were provided but not medically necessary. The False Claims Act may be used to address Medicare abuse, which is a pattern of improper practices that cause Medicare to incur unnecessary costs but aren’t necessarily fraudulent. The difference between the fraud versus abuse terms may be considered semantics at times, as it may depend on the intent of the biller or other factors.

Examples of Medicare fraud include:

• Billing for services or supplies that were not provided 
• Billing for services or supplies that were not medically necessary
• Altering medical records to support false claims
• Paying kickbacks or bribes to receive Medicare referrals
• Overbilling for services or supplies
• Submitting claims for non-covered services as if they were covered by Medicare

Examples of Medicare abuse include:

• Billing for services or supplies at a higher rate than the actual cost
• Providing medically unnecessary services or supplies
• Failing to meet Medicare requirements for documentation and record-keeping

As you can see the examples blend and bleed into each other, so if you suspect Medicare fraud or abuse, it is essential to report it. Reporting Medicare fraud and abuse not only helps protect patients and the integrity of the Medicare program but may also entitle you to a whistleblower award if the government recovers funds as a result of your report.

Step 2: Evidence Against Fraud

If you suspect Medicare fraud and abuse, it is important to speak with a whistleblower law firm before gathering any evidence to make sure you are lawfully gathering evidence you are entitled to. A whistleblower law firm can provide guidance on how to gather evidence in a way that protects your rights as a whistleblower and help to ensure that the evidence is admissible in court.

Once you have retained a whistleblower law firm like Brown LLC, with their expertise you can start gathering evidence to support your allegations. This evidence may include medical records, billing records, invoices, receipts, emails or other communications, and witness statements, but it’s best to take a holistic view about what you need to establish. You don’t need the concrete evidence in this case, you just need to prove credibly that a violation exists so it will open the door for it to investigate. 

It is important to gather evidence in a way that is legal and ethical. Your whistleblower law firm can provide guidance on how to gather evidence in a way that complies with the law and protects your rights as a whistleblower.

Step 3: Choose a Whistleblower Law Firm

Often individuals regret directly reporting the matter to the government and many years later want to involve a whistleblower law firm to try and obtain a whistleblower reward for their information, but unfortunately, that may be too late.  For a variety of reasons, it’s important that the government credits you early as the original source of the information. If you report it anonymously through a government hotline, the government may investigate the matter, and still may wind up speaking with you and worse if they feel you have some exposure, you may have led to your own problems with no upside.

Even if you are thinking of directly reporting Medicare fraud and abuse to the appropriate authorities, it is important to seek legal representation from a whistleblower law firm. A whistleblower law firm can help you navigate the legal process of reporting Medicare fraud and abuse and can protect your rights as a whistleblower.

If you are considering reporting Medicare fraud and abuse, it is important to choose a whistleblower law firm that has a proven track record of success in this area of law. The whistleblower law firm of Brown, LLC has a track record of success in the space, was cited in Lex Machina as one of the most prolific False Claims Act firms in the country over the last several years and offers a free, confidential consultation to anyone who believes they may have a valid whistleblower claim, and is led by a former Department of Justice, FBI Special Agent and Legal Advisor.  They can quietly and confidentially go over your legal options.   

Step 4: Working with Your Whistleblower Attorney

Once you have chosen a whistleblower law firm, you will discuss your allegations and the evidence. Your attorney will review your evidence and help you understand the strengths and weaknesses of your case. They will also help you determine the best course of action to take, whether that is to report the fraud and abuse to the appropriate authorities or to file a lawsuit under the False Claims Act.

Step 5: File a Whistleblower Complaint

If you and your attorney decide to file a whistleblower complaint, your attorney will draft and file the complaint on your behalf. The complaint will detail your allegations of Medicare fraud and abuse and will provide evidence to support your claims. Your attorney will also submit the complaint to the appropriate authorities, such as the Department of Justice or the Office of Inspector General.  Qui Tam firms like Brown, LLC will make sure that you sign off on the complaint before it’s filed and answer any and all of your questions, so you fully understand the process after the False Claims Act lawsuit is put into court.  Initially, the case is filed under seal, meaning the defendant will not know you filed anything against them and that seal may last several years as the case is investigated by the government.

Step 6: Cooperate with the Investigation

After you file a whistleblower complaint, the appropriate authorities will investigate your allegations of Medicare fraud and abuse. It is important to cooperate fully with the investigation and to provide any additional evidence or information that may be requested. Your whistleblower law firm should prepare you for an interview with the government and follow up with the government regarding any information that you may need and try to make sure they respond to any follow up requests from the government in a timely and accurate manner. 

Step 7: Protection from Retaliation

One of the biggest concerns for Medicare fraud whistleblowers is retaliation from their employer. Retaliation can take many forms, including termination, demotion, harassment, and blacklisting.

The False Claims Act statute provides strong measures to combat retaliation, but it doesn’t mean that it doesn’t occur. You often have several years to plan for when the lawsuit is finally unsealed and disclosed and you should use that time wisely to decide whether it’s a good fit to stay at the company, especially, if they’re doing a whole lot of bad things.  

Step 8: Receive Whistleblower Award

If the government recovers funds as a result of your whistleblower complaint, you may be entitled to a whistleblower award up to 30% of what the government recovers. The amount of the award can vary depending on factors, such as the significance of your contribution to the case, freshness of the information, and cooperation with the investigation. Each year hundreds of millions of dollars are awarded to whistleblowers under the False Claims Act (and also to SEC whistleblowers), but nothing’s ever guaranteed.

Your qui tam attorney will help you negotiate the terms of your award and work to help you receive the compensation you deserve for your efforts in exposing Medicare fraud and abuse.

In the end, reporting Medicare fraud and abuse is a complex process, but it is essential to protect patients and the integrity of the Medicare program. If you suspect Medicare fraud and abuse, it is important to seek legal representation from some of the best whistleblower law firms. By engaging a competent and accomplished whistleblower law firm you can report Medicare fraud and abuse with confidence and help ensure that those who commit fraud are held accountable.