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Your Options in Reporting Medicare Fraud at Work

April 1, 2024
Your Options in Reporting Medicare Fraud at Work

You’re working in earnest and have discovered Medicare Fraud or Medicaid Fraud and want to understand your options and how the various options will impact you. This will take you through your various options and the pros and cons of each option.  Here are the most common options about what to do in reporting Medicare Fraud at work:

Option 1 (RECOMMENDED) – Speak With a False Claims Act Lawyer Who Handles Medicare Fraud

Pros – Most of the best whistleblower law firms for Medicare Fraud will offer free consultations and can guide you through how the other options below may play out. Some of these Medicare Fraud law firms offer after hours and weekend consultations so you don’t have to speak at work.

Cons – There’s only a handful of law firms that have a track record of success in prosecuting Medicare Fraud cases under the False Claims Act. Firms that don’t have Medicare Fraud expertise or specialize in addressing Medicare Fraud may give you erroneous advice or set you on a bad path. This con can be cured by doing a little due diligence about what firms actually have successfully litigated Medicare Fraud matters in the past and going to them instead of a general practitioner.

Your Options in Reporting Medicare Fraud at Work

Option 2 (NOT RECOMMENDED) – Report the Fraud Internally With the Company’s Compliance Mechanisms

Pros – It’s quick, easy, and you may feel like you’ve done your part.  It’s a little bit of a positive sign if the company has robust reporting mechanisms that it promotes frequently with information about the False Claims Act and what constitutes Medicare Fraud.

Cons – Reporting Medicare Fraud through the company’s internal reporting mechanism may be a one-way ticket to getting fired! Even though the company may (or may not) encourage reporting of Medicare Fraud once you’ve reported it you’ve placed it in a bind.  If the company is very much aware of the fraud, it will look for a way to eliminate you.  If the company wasn’t “aware” of the fraud it will come in with its company attorneys and start locking you in with questions and signed statements that will be used against you later.  If the company has attorneys representing its interests, its best to have someone fighting for you in your corner as well (see Option 1).  As bizarre as it may seem something simple like you indicating you’ve seen the Medicare Fraud go on for a couple months may lead to your termination since they will say why didn’t you report it immediately and they may try to blame you for the situation.

Option 3 – Gather Evidence of the Medicare Fraud

Pros – Corroboration of your allegations of Medicare Fraud will help you establish your case no matter what route you take. You’re more likely to be believed if you have documented corroboration. Not to be relied on, but there is an exception under HIPAA to retain documents with PHI (protected health information) if intending to use the documents to report Medicare Fraud, but you’re better off doing this under the aegis of a whistleblower law firm.

Cons – You may be discovered in gathering documents or information that may lead to your termination. If you gather information that you’re not entitled to access, you may be fired or sued.  The evidence gathering portion is so critical that you are strongly cautioned against doing it yourself without professional whistleblower guidance from a qui tam law firm.

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Option 4 (MIXED BAG) – Report Medicare Fraud Directly With the Government

Pros – Although, it’s not recommended to report Medicare Fraud directly to the government without speaking with a Medicare Fraud attorney first, it is a possible route to proceed on. You can report it directly to the government by calling 1-800-MEDICARE (1-800-633-4227) and working through their menu to file a report. Certain things they will ask include, but are not limited to: how are you aware of the fraud, what is your position within the company, he name of the provider that you’re reporting, and the total amount that Medicare approved and paid either specifically or approximately.  Another pro is its somewhat quick (although sometimes not easy).  Before calling you will have to choose your route in deciding whether to report the fraud openly with your name attached or anonymously.  If you report it with your name then there’s a record with the government that you tried to do what’s right, but your name may be discoverable by the company later on with very little upside. If you do it anonymously you may be protected by being outed by the company unless the information you provided is so singular in nature, but you may not have down the road protection if the government decides to investigate and starts asking why you didn’t report the fraud.

Cons – One of the most common regrets people have who report Medicare Fraud directly to the government without retaining a False Claims Act lawyer is that if the case is resolved you are not eligible for a Medicare Fraud whistleblower reward.  Even if in earnest you’re thinking that you just want to report the matter and don’t want an award, when you read in the news that the company settled the matter for tens of millions of dollars and you could have been eligible for a million dollar Medicare Fraud whistleblower award or more, there’s always the feeling of regret and if you call a whistleblower law firm at that point it’s just too late.  Also, if you report the matter overtly, the government’s interest doesn’t perfectly align with yours and they may jam you up along the way to induce further cooperation. For example, if you say that you took screenshots of the patient records with your cell phone, the government may ask for the entire cell phone for imaging and who wants that headache. Also, if you interface with the government repeatedly without a lawyer they may indicate that your statements were inconsistent and can charge you with that.  Please note, that the government generally will not arbitrarily just try to jam people up who are reporting through their hotline, however, if they believe they can and that by doing so it may advance the government’s case, they may and then you will be hiring a paid attorney to help with your defense.

Option 5 – Report the Medicare Fraud by Filing a False Claims Act Lawsuit With a Whistleblower Law Firm

Pros – Most Medicare Fraud whistleblower law firms work on a contingency basis meaning that they’re only paid if they win your case. Which further means their economic interests are aligned with yours. The best whistleblower law firms will prepare you for every step of the process and by reporting Medicare Fraud under the False Claims Act you may be eligible for Medicare Fraud whistleblower rewards up to 30% of what the government recovers which in aggregate over the last decade has been hundreds of millions of dollars in whistleblower awards.  The case is initially filed confidentially under seal, meaning the defendant is not made aware of the litigation, so there’s a period of time your identity and complaint will not be known to the defendant.

Cons – If you’re not first to file then technically you may not be eligible for any whistleblower award so time is of the essence.  You can’t file the matter pro se, and you must use a whistleblower law firm or else your case will be dismissed.  Not every case is actually eligible for this route either because it’s not legally recognizable, or because the amount in controversy will make it so it’s not worth pursuing.  Since the statute calls for triple damages and some companies commit Medicare Fraud out of their own greedy economic necessity to keep the lights on at their own business, any Medicare Fraud settlement or Medicare Fraud judgment will not be collectable at the end of the day. Qui tam lawsuits under the False Claims Act for Medicare Fraud take a long time. Although some have been as short as one year, count on a multi-year experience in which there may be a roller coaster of emotions and possibilities. If you hire the wrong law firm, especially firms without a track record you may wind up doing all the work for nothing and have a less than graceful ending to the litigation.  Even with a seasoned qui tam law firm there’s still a chance that your case will not succeed due to factors outside of your control, such as the first to file rule, original source rule, or hundreds of other variables.

As you can read there’s a few options to consider if you’re aware of Medicare Fraud at work, but be mindful that with almost every option there’s pros and cons. The one common theme throughout every option is that you should look to avail yourself of a free, confidential consultation with a whistleblower law firm that handles Medicare Fraud, especially one that handles the matters of a contingency basis so their interests align with yours.