What is a Medicare Whistleblower?

When it comes to Medicare fraud, whistleblowers are the government’s first line of defense in the fight against prevalent fraud in the healthcare industry. Medicare fraud is a huge waste of taxpayer dollars and can ultimately lead to inappropriate care for innocent individuals. Even with the assistance of numerous whistleblowers and lawsuits and the recovery of billions of dollars, there are still billions that are never detected or recovered.

If you have become aware of a scheme meant to defraud the Medicare program, you may be able to act as a whistleblower. The experienced whistleblower attorneys at Khurana Law Firm can help.

Using tools like the federal False Claims Act or state false claims acts, the legal system has been able to hold healthcare providers who use fraudulent practices to steal from essential agencies like Medicare accountable. Using important whistleblower laws, individuals who come forward to report fraudulent activity have been critical in our nation’s fight to combat healthcare fraud.

The Prevalence of Medicare Fraud

Unfortunately, fraud is easily perpetrated against huge government healthcare programs such as Medicare. While systems for billing the program are meant to be easy and efficient, they are also easy targets for fraud. Unfortunately, undeserving providers can enter the system. Even large, well-known Medicare Advantage programs have been found defrauding the system to obtain higher reimbursements from Medicare.

A Medicare whistleblower is someone who is aware of fraudulent activity and agrees to come forward to file a civil lawsuit against the entity or provider committing the fraud. This is usually done under the federal False Claims Act or a similar state act. The government has the right to enter into the suit in order to recover its losses, or the individual whistleblower can go forward with the suit alone. There are substantial rewards available to these individuals if the lawsuit is successful.

Who Can Act As a Medicare Whistleblower?

When an employee of a healthcare facility, institution, organization, provider, or outside contractor or consultant becomes aware of activity meant to defraud the Medicare program, they have rights and protections under the law. But convincing the government to pursue these cases requires substantial evidence. Consequently, most whistleblowers are individuals who work within the company or organization they are reporting. Because these individuals have inside information regarding the fraudulent activity, their chances for success are much greater.

These individuals are eligible to receive rewards of between 15 percent and 30 percent of any funds the government obtains in the suit, providing the information they report is original information that leads to successful prosecution. Furthermore, these individuals are protected under the False Claims Act from any retaliation by their employer.

Whistleblowers have filed lawsuits under the False Claims Act for many types of fraudulent activities, such as

• Billing for unnecessary services
• Billing for things that were not used
• Unbundling services
• Upcoding services
• Chart mining
• Fraudulent risk adjustments
• Misdiagnosing
• Improper reporting
• Kickbacks
• Providers who are financially incentivized
• Illegal pharmaceutical marketing
• Compliance failures
• Pharmaceutical diversion
• Collusion
• Improper treatment of nursing home residents

If you are aware of activity that is used to defraud the federal Medicare program, you should get legal advice concerning your next move. At the Khurana Law Firm, P.C., our experienced whistleblower attorneys have dedicated our careers to representing those courageous individuals who come forward to report Medicare fraud. To get professional legal guidance, call us at (888) 335-5105 or contact us online to schedule a confidential, no-cost consultation.