Medicare Fraud

Medicare fraud includes deceptive acts intended to improperly collect money from the Medicare system. Some common examples of Medicare fraud include:

• Double billing: Receiving payment for a service from Medicare and another source
• Kickbacks: Offering or receiving payment for patient referrals or new business
• Medical identity theft: Using a patient’s or provider’s medical identity to fraudulently receive health care services, supplies or funding and then billing Medicare for them
• Phantom billing: Billing for a service or supplies a patient never received
• Unbundling: Billing Medicare more than once for the same service
• Unnecessary services: Prescribing or providing excessive or unnecessary services
• Upcoding: Billing for a more costly service than the patient received

Medicare fraud is illegal under federal law. Medicare is a government insurance program, so filing false claims against it is considered defrauding the government. Those who attempt to defraud the government are subject to administrative, civil and criminal penalties.

The Centers for Medicare and Medicaid Services (CMS) defines fraud as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.”

Who commits Medicare fraud?

Anyone can commit or be involved in Medicare fraud. Some common participants and examples of fraud they might commit include:

• Clinics: Healthcare clinics who submit claims for medical equipment or services that were not needed.
• Home health agencies: Homecare agencies and hospice providers who orchestrate fraud, waste and other abuses.
• Healthcare providers: Doctors and other medical providers who submit false claims to Medicare for services they did not do or that were not medically necessary.
• Hospitals: Physicians who refer patients to hospitals where they have a personal financial interest in services Medicare pays for.
• Medical Suppliers: Companies that bill Medicare for supplies other than what a patient received or for home medical equipment that was returned.
• Nursing homes: Nursing home administrators who include personal expenses in cost reports they submit to Medicare for reimbursement.

Medicare fraud is illegal. Anyone with knowledge can report instances of fraud to Medicare or the Department of Health and Human Services. Medicare fraud may also give rise to a qui tam claim under the False Claims Act.

Take these steps if you think you know about Medicare fraud:

• Document what you saw: Record dates, billing codes, names, and other details.
• Preserve evidence: Save any internal emails, reports, or invoices you legally have access to.
• Speak with an attorney: A lawyer can help you file a qui tam lawsuit under the False Claims Act.

Where to report fraud

If you know about potential Medicare fraud, you can report it to:

• Department of Health and Human Services Office of Inspector General (HHS-OIG)
• Centers for Medicare & Medicaid Services (CMS)
• Private attorneys with experience in Medicare whistleblower claims

If you choose to be anonymous on the OIG Hotline, the OIG won’t collect information that could be traced back to you. But, without your contact info, the OIG may not be able to thoroughly review and follow up on your complaint.

The Medicare fraud attorneys at Motley Rice can review your allegations. They can give you a comprehensive legal evaluation of your allegations and help build and file your case.

Who investigates Medicare fraud?

These government agencies investigate Medicare fraud:

• Office of Inspector General (OIG): Investigates fraud and abuse in HHS programs
• Department of Justice (DOJ): Litigates False Claims Act cases in coordination with whistleblowers
• Centers for Medicare & Medicaid Services (CMS): Oversees Medicare program integrity
• Others: State Medicaid Fraud Control Units, the FBI and U.S. Attorneys’ Offices

Legal guidance can help you determine if your knowledge might lead to a successful Medicare fraud claim.

Anyone with credible, non-public information about Medicare fraud may be eligible to file a qui tam whistleblower lawsuit under the False Claims Act.  The False Claims Act is a U.S. federal law that allows private citizens to sue those defrauding the government. The qui tam provision of the False Claims Act protects whistleblowers from retaliation. It also allows them to recover part of the government’s financial recovery for successful claims.

A qui tam lawsuit enables whistleblowers to file a lawsuit alleging fraud on behalf of the U.S. government in exchange for monetary rewards. Whistleblowers often include:

• Healthcare workers: Nurses, doctors, billing specialists and administrators who witness improper billing, upcoding or unnecessary procedures.
• Former employees: Individuals who left an organization but retained documentation or insight into fraudulent practices.
• Medical sales reps or contractors: Professionals who observe fraud related to medical devices, kickbacks or improper referrals.
• Patients and caregivers: Medicare beneficiaries or their families who notice irregularities or services they never received.

Whistleblowers do not need to have been directly involved in the fraud. But they must have specific and verifiable information about it. A legal professional can help you determine if you have a potential Medicare fraud claim.

Federal and state lawmakers want people to report illegal activity that defrauds the government. To encourage reporting, some federal and state laws allow whistleblowers to get a share of the money the government recovers.

Medicare fraud whistleblowers (relators) can make claims under the federal False Claims Act. They can receive rewards of 15% – 30% of the funds the government recovers if the case is successful.  The whistleblower’s share of the reward depends on whether the government got involved or not.

Here are some examples of what qui tam whistleblowers may be eligible for if their case leads to successfully recovered funds:

• If the government gets involved based on data unique to your submission, the reward is 15% – 25% of the recovery.
• If the government gets involved based on publicly available data, the reward is 0% – 10% of the recovery.
• If the government does not intervene, and you and your lawyers successfully pursue the lawsuit, the reward is 25% – 30% of the recovery.

The False Claims Act protects people from whistleblowing retaliation after they allege fraud. The legal protections offered to whistleblowers include: 

• Protection from retaliation such as demotion, termination, or harassment
• Right to reinstatement, back pay, and damages if retaliation occurs

Whistleblowers who prove retaliation can recover damages, including reinstatement to the same status they would be if retaliation had not happened. They may also get double back pay plus interest and compensation for emotional distress and attorney fees and costs. The whistleblower’s employer is not the only party that can be liable for retaliation. Others can be held responsible as well.

*We represent our clients on a contingency fee basis. This means you will not pay any fees or expenses unless you obtain a recovery. If you receive compensation, our fee will be a percentage of your recovery and will be calculated before any of your claim and lawsuit costs and expenses are deducted. Costs and expenses will be deducted and paid from your recovery.

What a Medicare fraud lawyer can do for whistleblowers

The FCA requires qui tam relators to have an attorney. Having an attorney with experience in Medicare fraud is crucial. They can guide whistleblowers through the complex process of reporting fraud committed against the government with experience.

People who file Medicare fraud claims must follow strict legal procedures. Medicare fraud lawyers with experience in whistleblower cases can guide clients and help protect their interests. They also improve the odds of success and help whistleblowers receive the compensation they deserve.

Motley Rice whistleblower lawyers represent numerous individuals in a broad range of whistleblower lawsuits and agency actions. In all cases, we work to protect the rights of potential whistleblowers and help them file accurate and thorough claims with the applicable court or agency.

If you think you may have a Medicare fraud whistleblower claim, consider contacting an attorney to get more information and find out your legal options. A lawyer with experience in whistleblower cases can advocate for you. Motley Rice understands how to protect whistleblowers and helps those filing qui tam claims obtain the compensation they deserve.

Read more about our whistleblower experience.