The False Claims Act (FCA) exists to prevent fraud and protect taxpayers. Numerous state and federal laws aim to combat abuse within the United States medical system. Unfortunately, some individuals still break these laws for financial gain. Thankfully, honest individuals step forward to expose such criminal activity within the healthcare field. These courageous individuals are known as whistleblowers. If you suspect healthcare fraud in Illinois or elsewhere, contact an experienced healthcare fraud attorney to ensure your rights are protected.
Examples of Healthcare Fraud
Healthcare fraud can take many forms and occur in virtually any clinical or administrative setting. Some of the most common schemes include:
- Billing for services that were never provided
- Submitting false or exaggerated claims to Medicare or Medicaid
- Performing and billing for medically unnecessary procedures
- Accepting kickbacks or bribes for referrals or services
- Overprescribing medications to increase reimbursements
- Modifying billing codes (upcoding) to charge for higher-paying services
- Unbundling procedures to bill separately for services that should be grouped
Illinois False Claims Act Laws
Healthcare fraud is addressed at both the federal and state level, providing whistleblowers with powerful legal tools to report and stop illegal conduct.
Federal Law
Under the federal False Claims Act (31 U.S.C. §§ 3729–3733), private individuals can bring a qui tam lawsuit on behalf of the U.S. Government if they have evidence of fraudulent claims submitted to federal healthcare programs. If successful, the whistleblower may receive 15% to 30% of any amount recovered through a settlement or judgment. These cases often involve complex evidence, and legal guidance is essential.
Illinois State Law
The Illinois False Claims Act (740 ILCS 175/1 et seq.) mirrors many of the provisions found in the federal statute. It allows whistleblowers to file lawsuits against individuals or organizations that defraud the State of Illinois — including its Medicaid program.
Key features of the Illinois FCA include:
- Civil penalties for each false claim
- The right of whistleblowers to receive a portion of the recovered funds
- Protections against employer retaliation for reporting fraud
- The state’s ability to intervene and take over the case, or allow the whistleblower to proceed independently
What Is a “Qui Tam” Lawsuit?
The term “qui tam” comes from a Latin phrase meaning “he who sues on behalf of the king as well as himself.” In modern legal practice, a qui tam lawsuit allows private individuals to file legal action on behalf of the government when they have firsthand knowledge of fraud against public funds.
To bring a successful case under the Illinois False Claims Act, the whistleblower must present credible, detailed evidence — not mere suspicion. Fortunately, laws are in place to protect whistleblowers from retaliation, and attorneys can help ensure that the process is secure, confidential, and effective.
Recent Illinois Healthcare False Claims Act Cases
Oak Street Health – $60 Million SettlementIn May 2024, Oak Street Health agreed to pay $60 million to settle allegations that it violated the False Claims Act by providing kickbacks to insurance brokers in exchange for patient referrals. These referrals led to the submission of claims to Medicare for services that may not have been medically necessary. The case involved joint federal and state action, including the State of Illinois. While the settlement did not admit liability, the outcome illustrates how whistleblower-initiated lawsuits can lead to substantial government recoveries.
KareFirst Management – Nearly $2 Million Settlement
In June 2024, Chicago-based KareFirst Management and its former owners agreed to pay nearly $2 million to resolve allegations that they caused the submission of false claims to Medicare and Medicaid. The company had developed a proprietary charting software used by psychiatric nurse practitioners, which allegedly generated documentation leading to upcoded claims. The lawsuit was filed under the qui tam provisions of the False Claims Act by a whistleblower — a former KareFirst employee.
Healthcare Fraud in Illinois by Region
Healthcare fraud can occur statewide, but some areas in Illinois face greater scrutiny due to population density, healthcare infrastructure, and prior investigations:
- Chicago and Cook County: As the state’s largest healthcare market, this region has seen numerous False Claims Act investigations involving hospitals, specialists, and home health providers.
- Peoria: With several major healthcare facilities and growing use of Medicaid services, Peoria has become a focus for state auditors and compliance investigations.
- Springfield: As the state capital and home to a large network of public health systems, Springfield is no stranger to whistleblower activity.
- Rockford and East St. Louis: These regions face ongoing challenges with healthcare access and oversight, making them vulnerable to potential fraud schemes.
Whether rural or urban, no region is immune — and every whistleblower plays a role in protecting patient care and public funds.
What Should I Do If I Suspect Healthcare Fraud in Illinois?
If you believe you’ve witnessed healthcare fraud in Illinois, discretion is essential. Your first step should be to contact a qualified Illinois healthcare whistleblower attorney. An experienced lawyer can help you understand whether you have a valid case, advise you on how to gather evidence, and protect your rights under both state and federal law.
During this process:
- Do not discuss the matter with coworkers or supervisors without legal guidance
- Maintain confidentiality and protect any relevant documentation
- Be prepared to secure alternate employment, if necessary, depending on your role and exposure
Filing a whistleblower case can feel overwhelming, but you don’t have to go through it alone. With skilled legal representation, you can take a stand against fraud — and potentially receive a financial reward for doing so.
(Note: While this guidance focuses on Illinois, the principles are applicable nationwide for those facing similar situations.)