Healthcare Fraud

Healthcare fraud can involve complicated claims between healthcare providers, patients, insurance companies, and government programs. This complicated process allows a lot of room for unscrupulous people to take advantage of the healthcare system to enrich themselves. When people commit healthcare fraud involving government programs like Medicare, Medicaid, or TRICARE, they are also taking advantage of the average taxpayer.

Many people who work in the healthcare field may suspect fraud or witness evidence of healthcare fraud in the course of their work. However, they still may be hesitant about confronting a supervisor or administrator about the suspected fraud. After all, reporting fraud could get them fired. Federal and state whistleblower laws provide financial rewards for reporting healthcare fraud and protect whistleblowers from retaliation.

Reporting Healthcare Fraud

Reporting healthcare fraud allows whistleblowers to be rewarded for coming forward to report illegal activity. Some of the most significant levels of healthcare fraud in the United States involve fraud against large government healthcare programs.

Whistleblowers can file a federal lawsuit on behalf of the government against individuals or companies committing fraud. Under the False Claims Act, a private individual can make a claim against anyone who knowingly commits healthcare fraud. A successful claim will allow the individual to recover up to 30% of the proceeds of the action or settlement, resulting in a significant financial reward. In 2015, whistleblowers filing these types of claims were awarded almost $600 million.

Types of Healthcare Fraud

One of the largest areas of fraud against the government involves healthcare fraud. The largest government healthcare programs include Medicare, Medicaid, and TRICARE.

  • Medicare provides health insurance to individuals 65 and older who have paid into the program through payroll taxes, as well as some individuals with certain disabilities.
  • Medicaid generally provides care to people with low-income and others with certain disabilities.
  • TRICARE is a federal program that provides civilian healthcare for military personnel and veterans and their families.

Thousands of healthcare providers, doctors, surgeons, dentists, chiropractors, nurses, hospitals, clinics, insurance companies, pharmaceutical companies, and support businesses are involved in these government healthcare programs. Unfortunately, some people involved in these massive government programs take advantage of the system to get rich by defrauding the government, sometimes at the expense of patient harm.

Examples of healthcare fraud may involve:

  • Billing for services that were never provided
  • Overbilling for services
  • Billing for unnecessary procedures
  • Billing for services acquired by illegal referrals
  • Upcoding or unbundling
  • Using false certifications
  • Misusing government grant money
  • Paying kickbacks to healthcare providers
  • Misrepresenting drug and medical device safety

When a healthcare provider, contract employee, or pharmaceutical worker witnesses questionable activity, they may blow it off as is or second guess themselves. However, the people who work in the healthcare field may be in the best position to spot potential fraud.

When an employee or contractor witnesses possible fraud, he or she may be able to file a whistleblower claim. A whistleblower claim may provide for a financial reward of up to 30% of the recovered damages and penalties. If a whistleblower is worried about getting fired for reporting fraud, state and federal whistleblower protections provide remedies for an employee who is retaliated against for reporting fraud or participating in a government investigation.

Healthcare Fraud Whistleblower Rewards

The False Claims Act is a federal law that prohibits fraud against the federal government, including fraud in government healthcare programs. Under 31 U.S.C. § 3729, a legal claim can be made against anyone who:

  • Knowingly presents a false or fraudulent claim for payment or approval;
  • Knowingly makes or uses a false record or statement material to a false or fraudulent claim;
  • Conspires to commit government fraud; or
  • Commits other forms of fraud against the government.

The False Claims Act allows private individuals to file a claim on the government's behalf, known as a qui tam lawsuit. An individual who exposes healthcare fraud perpetrated on the government can file a lawsuit and receive a share of the damages recovered. The process for these cases is very technical and requires a knowledgeable attorney to proceed to protect the rights of the whistleblower under the act.

A violation of the False Claims Act provides for triple the amount of damages to the government and a penalty of up to $11,000 per claim. An individual who files a qui tam lawsuit can receive between 15% and 30% of the proceeds of the action or settlement, depending on their level of participation in the case.

How do I File a Claim for Healthcare Fraud

When someone suspects healthcare fraud involving Medicare, Medicaid, or TRICARE, they may be able to file a claim under the False Claims Act. You must have an attorney to file claims under The False Claims Act.  A copy of the complaint is served first on the government in order for prosecutors to determine whether they want to prosecute the case. If the government decides to intervene and take primary responsibility for prosecuting the claim, the individual who filed the lawsuit generally has the right to continue as a party to the action.

However, if the government decides not to intervene in the case, the individual who filed the claim can still continue with the lawsuit. If the individual eventually wins the case or settles the case on behalf of the government, they may be eligible for a larger share of the recovered damages and penalties.

For example, an employee who handles billing for a clinic notices a doctor submitting bills to Medicare for the treatment of patients that were never treated. The employee, through his or her attorney, files a claim under the False Claims Act and the government takes the case. The doctor is found guilty of defrauding the government and has to pay the government $5 million in damages and penalties. As a result of the employee reporting the fraud and cooperating with government prosecutors, the employee could receive an award of up to 25% of the proceeds, or up to $1.25 million.

Protections for Healthcare Fraud Whistleblowers

One of the primary reasons people do not report fraud is because they are concerned about the possible repercussions. A healthcare employee who reports suspicious activity could be called a rat, told they are being paranoid, or even be fired. However, state and federal whistleblower protection laws provide remedies for employees who are retaliated against for reporting unlawful activity.

If a healthcare employee is fired, demoted, suspended, threatened, or harassed because they cooperated with fraud investigators or reported fraud, the individual may have a claim for damages, including:

  • Back pay
  • Interest on back pay
  • Front pay
  • Reinstatement
  • Special damages
  • Legal fees

Healthcare Fraud Whistleblower Attorneys

We understand how difficult it can be to come forward to report healthcare fraud in the workplace. Your job may be at risk and you may be concerned about how coming forward will affect your career and your reputation. At Schechter Legal Group, we can help protect you and your family and fight to get you the reward you deserve. Contact the Schechter Legal Group to report healthcare fraud today.

Contact Us

If you want to report fraud against the government but you are concerned about your future, we are here to help. We will help protect your rights as a whistleblower to obtain the reward you deserve. Contact the Schechter Legal Group today.

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