People who become aware of an individual or business defrauding the government can assist the government by bringing legal action against the perpetrator. These employees or former employees are known as whistleblowers, and one of the most common forms of whistleblower complaints involve Medicare fraud.

Why Is the Government So Concerned with Medicare Fraud?

Medicare fraud costs taxpayers billions of dollars. Since Medicare is a large healthcare program, the potential for fraud is rampant, and in many cases the government would not be able to carry out investigations without the assistance of whistleblowers.

How Does A Whistleblower Help Stop Medicare Fraud?

A whistleblower refers to a current or former employee who has evidence or reason to believe that Medicare fraud has occurred. There are many different types of Medicare fraud and a whistleblower can alert the government to an ongoing scheme. The whistleblower does this by filing a lawsuit against the person or company believed to have scammed the government.

The government may join the lawsuit “in order to guarantee success and be part of any negotiations and conduct of the case,” however this is not always the case, explains law.com. Whether the government joins the case or not, the plaintiff “is entitled to a percentage of the recovery of the penalty (which may include large amounts for breach of contract) as a reward for exposing the wrongdoing and recovering funds for the government.”

What Is Medicare Fraud?

Medicare fraud can include many different schemes, but most frequently refers to:

• Making referrals that are prohibited for designated health services
• Knowingly offering, soliciting, paying kick-backs or receiving money to reward or induce referrals for services or items that are reimbursed by federal health care programs

Medicare fraud is committed when a business or individual knowingly submits false claims or makes misrepresentations about claims to receive a federal health care payment, according to the Centers for Medicare and Medicaid.

Who Can Commit Health Care Fraud?

Medicare fraud schemes range from individuals to widespread activities carried out by a group or an institution. Anyone can be involved in Medicare fraud. Some common examples include:

• Billing Medicare for appointments that patients do not keep
• Knowingly billing for services or supplies that were not provided or rendered
• Knowingly billing for services at a level of complexity higher than the actual services provided
• Ordering medically unnecessary items or services for patients

What Are the Potential Outcomes of Medicare Fraud?

It is illegal to defraud the federal government. Committing Medicare fraud exposes entities or individuals to criminal, administrative or civil liability and can result in fines, imprisonment, and other penalties.

How Much Money Is Falsely Billed Through Medicare?

In June 2018, the U.S. Department of Justice (DOJ) announced the agency’s largest ever health care fraud enforcement action, during which 601 people, including dozens of doctors, were arrested for “their alleged participation in health care fraud schemes involving more than $2 billion in false billings.”

What Can Whistleblowers Do to Stop Health Fraud?

Whistleblowers can file a False Claims Act lawsuit, also known as a qui tam or whistleblower lawsuit. Whistleblowers should always seek insight from an experienced attorney before moving forward with a claim.

This article is not legal advice. It is presented
for informational purposes only.