Reporting Medicare Fraud

Whistleblowers who report Medicare fraud help to protect the government’s limited resources and assist in ensuring that Medicare beneficiaries receive more services rather than have funds siphoned away. In addition, the whistleblowers can earn up to 30% of what the government recovers as a whistleblower reward for doing the right thing and reporting Medicare fraud the right way. With the economic consequences significant and the potential for actual harm to occur, if you see something, say something, and consider consulting with a Medicare fraud law firm about your rights and the best way to blow the whistle.

What is Medicare Fraud?

Medicare fraud is defined as any intentional deception or misrepresentation that is made to bill or receive Medicare funding as an individual or as an entity. Every year, fraud is estimated to cost the government tens of billions of dollars. Cumulative fraud may also have a negative impact on Medicare beneficiaries, as it may result in higher costs and restricted access to care. Medicare fraud can also lead to unethical practices by institutions, such as the recommendation of unnecessary tests, or worse the performance of unneeded surgeries which can jeopardize a patient’s health and well-being.

As a Medicare fraud whistleblower, reporting Medicare fraud and abuse is not only the right thing to do, but it is also required to protect patients and the Medicare program’s integrity. However, reporting Medicare fraud can be a complicated and intimidating process, especially for those unfamiliar with the healthcare industry and the legal system.

Reporting to authorities has the potential to bring justice, but unless you report it correctly, you may be ineligible for a whistleblower award or worse potentially looked at as a suspect. If you want to receive a whistleblower award, you must file a False Claims Act case with a qui tam law firm to address systemic Medicare fraud and in turn your proper reporting could entitle you to a whistleblower award of up to 30% of what the government recovers.

Examples of Medicare Fraud

Medicare fraud examples include:

• Billing for services not provided- When a provider bills Medicare for services that were never provided to a patient, this is fraudulent. A doctor or a home health aide, for example, may bill Medicare for a home health visit that never occurred.
• Upcoding- This occurs when a provider bills Medicare for a more expensive service than was actually rendered. For example, a doctor may bill Medicare for a level 4 office visit when only a level 3 visit was provided or routinely code a procedure up indicating more time was spent than it actually was or the level of complexity was more intense or someone was symptomatic with Covid when in fact they weren’t.
• Kickbacks- Referral of  a patient to another provider in exchange for a commission or inducements to have physicians prescribe certain products in the case of pharmaceutical fraud. A doctor, for example, referring a patient to a physical therapist in exchange for a portion of the physical therapist’s fees if there is a government payor is inherently considered Medicare fraud or Medicaid Fraud since it is a de facto violation of the Anti-Kickback Statute (AKS).
• Improper self-dealing, in which a physician refers patients to other entities owned by the physician without disclosing the physician’s interest in the derivative companies, also known as a Stark Law violation.
• Unnecessary medication- This occurs when a doctor prescribes a medication to a patient that is not medically necessary. A doctor, for example, may prescribe a pain reliever to a patient who is not in pain which led to the opioid epidemic.

Medicare fraud can be committed by healthcare providers, patients, or others in the healthcare industry; however, the False Claims Act statute seeks to address systemic issues from entities that either routinely defraud Medicare or have received significant overpayments and refuse to surrender their ill-gotten gains.  When pharmaceutical fraud occurs, it can morph into other dimensions, such as off-label promotion of products, failure to adhere to commonly accepted good manufacturing practices (GMP or CGMP), or providing lavish trips, food, sports tickets, and so on to induce referrals. 

What Are Some Red Flags to Detect Medicare Fraud?

There are numerous red flags that can point to Medicare fraud. The following are some of the most common red flags:

• Offering cash or other incentives to patients to see a specific provider- This could indicate that the provider is attempting to increase their Medicare billings and is inherently considered an unlawful kickback scheme.
• Billing for non-existent services or supplies: This is a common type of Medicare fraud that can be challenging to detect. Insiders, on the other hand, can look for a few things. For instance, if a provider bills for a large number of services or supplies that are not typically required for a specific patient’s condition, this could be a red flag. This is also known as “phantom billing”.
• Offer or perform unnecessary services in order to charge Medicare for more services.
• Giving beneficiaries unsolicited supplies: If a provider sends unsolicited supplies to beneficiaries, this could be a red flag. Furthermore, if the supplies are not actually required by the beneficiary, this could be another red flag that insiders can be on the lookout for.
• Another type of Medicare fraud that can be difficult to detect is prescribing or providing excessive or unnecessary tests and services. 

Reward for Reporting Medicare Fraud

Whistleblowers who report Medicare fraud may be eligible for substantial monetary rewards ranging from 15% to 30% of the total amount recovered under the False Claims Act. To be eligible for a Medicare fraud whistleblower reward, you must have firsthand knowledge of the fraud and be the first to report through the use of a  whistleblower law firm, preferably one that has experience in this space and can work seamlessly with the Department of Justice. 

Recent Successes in Medicare Fraud Whistleblower Cases

In 2023, Vasso Godiali, a vascular surgeon from Bay City, Michigan, was sentenced to 80 months in prison for his role in a large healthcare fraud scheme. Godiali submitted false claims for vascular stent placements and thrombectomies that he did not perform, costing health-care programs such as Medicare, Medicaid, and Blue Cross/Blue Shield of Michigan millions of dollars. Godiali was sentenced to pay $19.5 million in restitution to the affected programs as part of his sentence. In addition, he has agreed to pay up to $43,419,000 to settle civil False Claims Act allegations. https://www.justice.gov/opa/pr/michigan-vascular-surgeon-sentenced-80-months-prison-health-care-fraud-conviction-and-agrees

In 2023, a renowned plastic surgeon based in Beverly Hills, California, along with his son, medical practices, and billing company, have agreed to pay a substantial sum of nearly $24 million, specifically $23.9 million. This resolution aims to address allegations that they contravened the False Claims Act by knowingly submitting or facilitating the submission of fraudulent claims to both Medicare and Medicaid, government healthcare programs. According to the allegations, the settling parties falsified the location of service for skin grafts and billed for single-use skin substitute products multiple times. It is alleged that the Settling Parties manipulated the place of service code on skin graft claims in order to fraudulently increase Medicare and Medicaid reimbursement. Furthermore, it is claimed that Dr. Aronowitz failed to properly dispose of unused single-use skin graft materials and instead used them in subsequent procedures involving other Medicare and Medicaid beneficiaries, resulting in thousands of instances of double billing.https://www.justice.gov/opa/pr/beverly-hills-plastic-surgeon-agrees-pay-nearly-24-million-settle-false-claims-act

Whistleblower Protection

The False Claims Act protects whistleblowers who report Medicare fraud. The False Claims Act protects whistleblowers from retaliation, such as job loss, demotion, or harassment. If a whistleblower faces retaliation for reporting Medicare fraud, they can sue under the False Claims Act. Back pay, front pay, and attorneys’ fees may be awarded to the whistleblower.

The False Claims Act is a powerful tool for protecting whistleblowers and combating Medicare fraud. If you believe Medicare fraud is taking place, you should contact a whistleblower law firm. A whistleblower law firm can help you understand your rights and options, and if you choose, they can represent you in a lawsuit combatting retaliation, but if you seek to file under the False Claims Act you must use a qui tam law firm as pro se litigation is forbidden

Who to Report Medicare Fraud to?

Reporting Medicare fraud is critical to preserving the program’s integrity and preventing future fraud. If you suspect Medicare fraud, you can report it 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 help of a whistleblower law firm, that has experience litigating Medicare fraud cases.

Brown, LLC’s whistleblower attorneys are dedicated to assisting people who have inside knowledge of healthcare fraud, including Medicare fraud, and have successfully recovered millions of dollars for whistleblowers; however, past results do not guarantee future success, and they offer free, confidential consultations.