Medicare provides health insurance for people over 65 years old, certain younger people with disabilities, or people with end stage renal disease. Medicare is a federally funded program and all providers receiving payments from Medicare must follow federal and state regulations and laws. Sadly, there are billions of dollars lost each year due to fraudulent claims. As a result, stiff financial and legal penalties may be assessed to anyone proven to file false claims.
The healthcare fraud lawyers at Di Pietro Partners represent Medicare whistleblowers. We understand the courage it takes to step forward and the importance of ensuring your rights and interests are protected throughout the process. We’ve prepared this article as a guide for Medicare whistleblowers and what they can do if they expect fraud. This includes how to report Medicare fraud.
Types of Medicare Fraud, Waste, and Abuse
Fraudulent conduct using federal monies hurts taxpayers and quite often patients. Some examples of Medicare fraud include:
- Billing for non-existent services
- Billing for prescriptions or medical equipment not received
- Padding a bill or changing a code to receive a higher payment
- Sending a patient for unnecessary tests so clinic receives more money
- Receiving kickbacks from suppliers or clinics
- Telehealth fraud- This occurs when Medicare is billed for a telehealth visit that never took place.
- Providing unnecessary treatment
Recent Medicare Whistleblower Cases
Recently, numerous Medicare whistleblower cases have made the news. The lawsuits became newsworthy due to the large amounts of money involved in fraudulent schemes and the huge penalties attached to committing these crimes. Noteworthy cases include:
- The U.S. Department of Justice Office of Public Affairs issued a press release on Tuesday, January 30, 2024. The article explained how a California man was sentenced to 10 years in prison for billing Medicare approximately $234 million for various lab tests, despite the fact he was excluded from participating in Medicare. The man was previously convicted in 1990 and 2001 in New York and California. After each conviction, he was ordered NOT to participate in Medicare or Medicaid programs. Evidently, he didn’t listen. In addition to 10 years in prison, he must forfeit $31,761,286.21, two residential properties, and one business property.
- A Florida businessman was ordered to pay $27 million for Medicare fraud. He billed Medicare for cancer genomic testing that was not medically necessary. It’s important to note, he owned the diagnostic laboratory.
- A Pennsylvania pharmacist submitted claims to Medicare Part D which is the prescription part of the plan. Well, the claims were then traced to non-existent orders and the drugs were never given to any patients. The pharmacist pled guilty and was sentenced to 15 months in prison and $166,000 restitution.
- Operation Brace Yourself (2019) – Over $1.2 billion in fraudulent claims made by dozens of healthcare executives and telemedicine executives led to charges. The group billed Medicare for equipment never used or received.
- Michigan doctor’s chemotherapy fraud (2014) – This was a horrific case. Dr. Farid Fata was convicted of administering chemotherapy to over 500 patients who didn’t have cancer. Medicare received and paid $34 million of fraudulent claims from this doctor.
What Should I Do if I Suspect Medicare Fraud?
If you suspect Medicare fraud, step one is to contact a Medicare fraud attorney. You can file a lawsuit under the False Claims Act (FCA). At this point you are known as a whistleblower. Tell NO ONE but your attorney. An experienced attorney will guide you through the process. You may need to know how to legally collect evidence for the case, or your attorney will handle this part. Either way there are steps to follow. Also, a whistleblower may receive a reward. Your experienced attorney will explain the legal implications and how reward money works. Most importantly, you are stopping criminal behavior that may be endangering vulnerable patients.
Medicare Whistleblower Rewards and Protections
Under qui tam, you may receive a portion of recovered funds. For example, in some cases whistleblowers receive at least 15% but not more than 30% of recovered funds. Your attorney will explain the possible amount to you. It’s important to note that state and federal laws offer protection to whistleblowers. At the federal level, the False Claims Act (FCA) offers protection. This act forbids employers from firing, demoting, or harassing employees for reporting fraud. In fact, if an employer does retaliate, the employee may sue the employer for damages. So, if you notice Medicare fraud contact an attorney immediately to discuss the situation.
Medicare Whistleblower FAQ
Q. What happens when you report Medicare fraud?
Once you report Medicare fraud, the relevant agency (OIG or CMS) will review your report to determine if there is enough information to warrant an investigation. If an investigation is initiated, it will be conducted confidentially. You may or may not be contacted for further information, depending on the specifics of the case. Investigations can lead to various outcomes, including recovery of stolen funds, penalties for the fraudsters, and in some cases, criminal prosecution.
Q. Where do you report Medicare fraud?
Medicare fraud can be reported to: The Office of Inspector General (OIG), The Centers for Medicare & Medicaid Services (CMS), The Senior Medicare Patrol (SMP), which can also assist with fraud reporting and provides resources for Medicare beneficiaries. When considering reporting Medicare fraud, engaging a specialized Medicare fraud law firm can significantly enhance the process beyond simply submitting a report to regulatory bodies. Medicare fraud attorneys bring a wealth of expertise in healthcare law, ensuring that reports are not only accurately filed but also meticulously documented and presented in a manner that underscores the seriousness of the allegations.
Q. How do you report Medicare fraud anonymously?
If you wish to report Medicare fraud anonymously, it’s advised that you do so through a reputable law firm. When you do it this way, your legal rights are protected through attorney-client privilege. While providing your contact information can be helpful for the investigation, it is not mandatory, and your report can still be submitted and processed anonymously.
Q. What are the penalties for Medicare fraud?
The penalties for Medicare fraud may be quite severe. Civil or criminal charges are filed depending on the severity of fraud. Healthcare providers found guilty of Medicare or Medicaid fraud may face substantial fines or imprisonment. Also, the provider may be excluded from participating in any government healthcare program in the future. Finally, the guilty party may face civil lawsuits brought by the government or whistleblowers seeking damages.
Q. What is the cost of a Medicare fraud lawyer?
The cost of hiring a Medicare fraud lawyer can vary widely based on several factors, including the complexity of the case, the lawyer’s experience, and the law firm’s billing practices. The Medicare fraud attorneys at Di Pietro Partners work on a contingency fee basis on whistleblower (qui tam) cases under the False Claims Act. This means the lawyer only gets paid if you win the case or reach a settlement, taking a percentage of the recovered funds as their fee. This percentage can vary but typically ranges from 20% to 40% of the recovery.
