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, Medicare loses substantial amounts each year through improper payments, including some payments involving fraud and abuse. However, not every improper payment is fraudulent. 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 suspect fraud. This includes how to report Medicare fraud.
Key Takeaways
Not every Medicare improper payment is fraud. Medicare fraud generally involves knowingly submitting or causing false or fraudulent claims or engaging in other prohibited conduct to obtain Medicare payments.
- Common Medicare fraud schemes can involve billing for services that were never provided, upcoding, medically unnecessary treatment, kickbacks, telehealth fraud, and fraudulent durable medical equipment claims.
- Depending on the facts, an eligible whistleblower may be able to file a qui tam lawsuit under the False Claims Act on behalf of the United States.
- Eligible False Claims Act relators may generally receive 15% to 25% of the recovery when the government proceeds with the case, or 25% to 30% when the government declines and the relator successfully pursues the action, subject to statutory exceptions.
- Federal law also provides retaliation protections for certain employees, contractors, and agents who engage in qualifying protected activity related to suspected False Claims Act violations.
Who Can Be a Medicare Whistleblower?
Medicare fraud is often discovered by people who work inside healthcare organizations and see billing, treatment, documentation, reimbursement, or referral practices firsthand. Under the False Claims Act, a private person may bring a qualifying qui tam action on behalf of the United States, although statutory restrictions and other legal requirements can affect whether a particular person or claim is eligible. U.S. Code
Potential Medicare whistleblowers may include:
- Medical billers and coders
- Physicians and medical directors
- Nurses and nurse practitioners
- Compliance officers
- Hospital and health system employees
- Skilled nursing facility employees
- Home health and hospice employees
- Pharmacy and laboratory employees
- Durable medical equipment company employees
- Practice administrators and healthcare executives
- Contractors, consultants, and third-party vendors
A whistleblower does not have to be a doctor or executive. Employees who understand how Medicare claims are coded, documented, approved, submitted, or reimbursed may be especially well positioned to recognize patterns that patients or outside investigators would not see.
However, having information about suspected Medicare fraud does not automatically mean someone can file a qui tam case or receive a whistleblower award. Eligibility depends on the facts and the requirements of the False Claims Act, including statutory restrictions that can apply to certain cases.
Types of Medicare Fraud, Waste, and Abuse
Fraudulent conduct using federal monies hurts taxpayers and quite often patients. Some examples of conduct that may constitute Medicare fraud or abuse, depending on the facts and intent involved, include:
- Billing for non-existent services
- Billing for prescriptions or medical equipment not received
- Padding a bill or knowingly changing a code to receive a higher payment
- Sending a patient for unnecessary tests and billing Medicare for those services when the required knowledge or intent is present
- Receiving or paying improper kickbacks from suppliers or clinics
- Telehealth fraud- This occurs when Medicare is billed for a telehealth visit that never took place.
- Providing and knowingly billing Medicare for 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, including his interests in two residential properties and one business property. Medicare paid approximately $31.7 million on the claims.
- A Florida businessman and several companies agreed to pay more than $27 million to resolve False Claims Act allegations involving medically unnecessary cancer genomic testing and illegal kickbacks. Daniel Hurt owned or operated several laboratory companies involved in the alleged scheme. The settlement resolved allegations brought in three whistleblower lawsuits, and one relator was eligible to receive up to $4.7 million, or 17% of the government’s recovery.
- In 2026, Crown Medical Solutions LLC and its owners agreed to pay $825,000 to resolve False Claims Act allegations that they billed Medicare for durable medical equipment that was medically unnecessary and/or not properly prescribed. The case originated from a qui tam whistleblower lawsuit, and the relator received approximately $123,750 from the settlement.
- Operation Brace Yourself (2019) – The Department of Justice charged 24 defendants in connection with alleged telemedicine and durable medical equipment schemes involving more than $1.2 billion in losses. Prosecutors alleged that DME companies paid illegal kickbacks and bribes for Medicare beneficiary referrals and submitted claims involving medically unnecessary braces.
- Michigan doctor’s chemotherapy fraud (2014) – This was a horrific case. Dr. Farid Fata pleaded guilty to healthcare fraud and related offenses after administering medically unnecessary infusions or injections to 553 patients. His scheme involved approximately $34 million in fraudulent claims submitted to Medicare and private insurers.
What Should I Do if I Suspect Medicare Fraud?
If you suspect Medicare fraud, step one is to contact a Medicare whistleblower attorney. Depending on the facts, you may be able to file a qui tam lawsuit under the False Claims Act (FCA) on behalf of the United States. A person who files a qui tam action is known as a relator. Because False Claims Act cases have specific filing and confidentiality requirements, it is generally wise to speak with an attorney before deciding how to report the suspected fraud or disclose information about a potential case. An experienced attorney will guide you through the process.
You may need to know how to lawfully preserve or identify evidence for the case, or your attorney will handle this part. Potential whistleblowers should be cautious about accessing, copying, or removing employer records that they are not authorized to possess, particularly records containing confidential, privileged, or protected health information. 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 helping expose suspected fraudulent conduct that may be endangering vulnerable patients.
Medicare Whistleblower Rewards and Protections
Under qui tam, you may receive a portion of recovered funds. If the government proceeds with a successful False Claims Act case, an eligible relator generally receives between 15% and 25% of the proceeds. If the government declines to intervene and the relator successfully pursues the case, the relator generally receives between 25% and 30%. These percentages are subject to statutory exceptions and may be reduced in certain circumstances. 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. The FCA protects certain employees, contractors, and agents from being fired, demoted, suspended, threatened, harassed, or otherwise discriminated against because of lawful acts taken in furtherance of an FCA case or other lawful efforts to stop suspected False Claims Act violations. In fact, if an employer does retaliate, a qualifying whistleblower may be entitled to remedies including reinstatement, two times the amount of back pay, interest, certain special damages, litigation costs, and reasonable attorneys’ fees. 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 will review the information to determine what action, if any, is appropriate. Not every report results in an investigation. If an investigation is initiated, the agency may contact you for additional information if you identified yourself when submitting the report. 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. How Long Do You Have to File a Medicare False Claims Act Case?
The False Claims Act has specific filing deadlines. In general, a False Claims Act case may not be brought more than six years after the alleged violation, or more than three years after the material facts were known or reasonably should have been known by the responsible U.S. government official, whichever period ends later. However, an action generally cannot be brought more than 10 years after the alleged violation. Because the applicable deadline can depend on the facts and timing of a particular case, potential Medicare whistleblowers should not assume they have the full 10 years to act. Speaking with an attorney early can help determine which deadline may apply.
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.
