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How to Report Medicare Fraud

Establishing Fraud

The subject of Medicare Fraud is a very complex one and can necessitate the aid of an attorney who is well versed in this particular area. For the purpose of halting acts of Medicare fraud against the government, a whistleblower might file a civil lawsuit under the False Claims Act. Any individual or entity that has witnessed fraudulent actions against federal programs or contracts can stand as a whistleblower. The kind of lawsuit that a whistleblower may initiate is known as a qui tam

This is how a qui tam lawsuit works. The claimant is filing suit on behalf of the government. They are referred to as a “relator”. Essentially, the relator is assisting the government in eliminating waste, fraud and abuse by stepping forward. Oftentimes, The relator is entitled to a financial reward in a successful qui tam lawsuit. If you have encountered fraud, it’s a good idea to consult an attorney to see if you are eligible to initiate a qui tam lawsuit.

Picking the right qui tam attorney from the start is the key to  a successful outcome. Here are some factors to take into account when choosing a qui tam attorney:

  • The attorney’s experience in qui tam and other cases involving Medicare Fraud
  • What resources the attorney has at his or her disposal
  • The attorney’s xperience and familiarity with the kinds of whistleblower cases the government customarily prioritizes and pursues
  • The attorney’s level of understanding of the risks involved with filing these suits

An Explanation of Qui Tam 

The Federal False Claims Act is a federal law that imposes liability on persons and entities that defraud governmental Medicare and Medicaid programs. Also known simply as the False Claims Act, this is the government’s primary ammunition in combating fraud. As evidence, over 70% of all False Claim lawsuits were brought by whistleblowers as of 2012. From 1987 to 2013, $27.2 billion dollars were recovered in qui tam cases initiated by whistleblowers. More than 700 False Claims actions were brought by whistleblowers in 2014 alone.

Under the False Claims Act, any Medicare payment associated with illegal activity or noncompliance with federal regulations could be classed as Medicare Fraud. Indeed, there are numerous diverse kinds of Medicare Fraud.  One common factor among them is that the fraud has attempted to collect money from a government payor under false pretenses. Here are some practices that may constitute fraud (this list is by no means exhaustive):

  • Billing Medicare for a good or service that is not medically necessary
  • Billing Medicare in a fashion that fails to  accurately represent the goods or services that were actually provided
  • Billing Medicare for goods or services that were never rendered at all
  • Failure to comply with FDA regulations
  • Violations of the Anti-Kickback Statute
  • Violations of the Stark Law
  • Improper or noncompliant documentation of personal information

The way a whistleblower reports some fraudulent practice they have encountered to the government is under the qui tam provision to the False Claims Act. In qui tam lawsuits, the government sometimes finds just cause to intervene and join the lawsuit. If the government is successful in recovering damages, the whistleblower is entitled to up to 25% of what the government recovers.

Things to consider when deciding whether to pursue a qui tam case as a whistleblower: 

  • How likely is it that the defendant will be liable for a substantial judgment
  • What liability under the False Claims Act is the defendant guilty of
  • What harm was caused to the government
  • Will you be able to pursue the lawsuit as a whistleblower
  • What risks are involved with filing suit

It’s imperative for whistleblowers to be aware that the False Claims Act prohibits:

  • Knowingly bringing forth, or causing to be brought forth a false claim for payment or approval
  • Knowingly producing, utilizing, or causing to be produced or untilized, a false record or statement material to a false or fraudulent claim
  • Colluding to commit any violation of the False Claims Act
  • The certification of receipt of property on a document without any verification of the veracity of the information therein
  • Falsifying the certification of the type or amount of property to be employed by the Government
  • Knowingly purchasing Government property from an unauthorized officer of the Government and
  • Knowingly producing, utilizing, or causing to be produced or utilized a false record to avoid or bring down the amount of an obligation to pay or transmit property to the Government

For these prohibited acts, the False Claims Act imposes liability for treble damages and a civil penalty ranging from $5,000 to $10,000 per claim for anyone who knowingly submits or causes the submission of a false or fraudulent claim (treble damages are a multiple of, and not an addition to, actual damages). Nonetheless, certain claims are also not actionable. These concerns should be addressed with an attorney.

How Our Attorneys Can Assist You

Oberheiden, P.C. attorneys possess an impressive depth of knowledge and experience with qui tam lawsuits. They are customarily filed under seal in federal district court in accordance with the Federal Rules of Civil Procedure. Complications could arise that have the potential to harm a person pursuing a claim without counsel.

Boasting many years of prosecutorial experience in Medicare Fraud and with qui tam lawsuits, our attorneys are thoroughly prepared to help you navigate your qui tam lawsuit. A number of our lawyers were themselves erstwhile federal prosecutors for the United States Attorney’s Office. Because they are former prosecutors, they are intimately acquainted with the ins and outs of the federal legal system as well as the evidentiary obligations that are necessary for a successful whistleblower claim.

Our lawyers have a long, impressive track record of work with the FBI, the Office of Inspector General, the Department of Health and Human Services, and other federal law enforcement agencies. Their requisite knowledge and experience can arm clients with all they need to present a well prepared claim to the government and increase the chances of a successful outcome.


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