Medicare provides healthcare coverage primarily to people age 65 and older, as well as certain younger people with disabilities, End-Stage Renal Disease (ESRD), or ALS. The program involves more than one trillion dollars in federal healthcare spending each year, and its size and complexity can make fraudulent billing difficult to detect. Whistleblowers, healthcare workers, patients, and other insiders can play an important role in identifying suspected Medicare fraud.

The Medicare fraud lawyers at Di Pietro Partners represent whistleblowers with knowledge of suspected false claims, improper billing, medically unnecessary services, kickbacks, and other Medicare fraud schemes. We understand the significance of stepping forward and the importance of protecting your rights throughout the process.

Our attorneys handle eligible False Claims Act whistleblower matters on a contingency-fee basis. For qualifying cases, attorney fees are generally contingent upon obtaining a recovery, subject to the terms of the firm’s written fee agreement.

If you suspect Medicare fraud and are considering taking action, contact Di Pietro Partners for a confidential consultation.

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What is Medicare Fraud/Abuse?

Medicare fraud generally involves knowingly or intentionally using false information, claims, or representations to improperly obtain money or benefits from the Medicare program. Medicare abuse is different. It can involve practices that result in unnecessary costs or payments for services that are not medically necessary or otherwise do not meet applicable standards. Whether conduct constitutes fraud or abuse can depend on the specific facts, including the person’s knowledge and intent.

Medicare is designed to provide healthcare primarily to people age 65 and older, as well as certain younger people with disabilities, End-Stage Renal Disease (ESRD), or ALS. Given the program’s vast scale and intricate nature, effective detection and prevention of fraud often depend in part on information provided by patients, healthcare workers, industry insiders, and other whistleblowers.

Medicare fraud can take many forms, all sharing the common goal of improperly obtaining Medicare funds or benefits. Some prevalent types of fraud include:

Billing for Services Not Rendered – This involves healthcare providers submitting claims for procedures or services that patients did not actually receive. An example would be a therapist billing Medicare for comprehensive physical therapy treatments when only basic massage therapy was provided.

Upcoding – In this scenario, providers intentionally use higher billing codes for services or procedures than what was actually performed, aiming to receive higher reimbursements than they are entitled to.

Unnecessary Procedures – Billing Medicare for medically unnecessary procedures may constitute fraud when the required knowledge or intent is present. Depending on the circumstances, medically unnecessary billing may also constitute abuse or result in other civil or administrative liability. This is particularly concerning when it targets vulnerable populations, such as the elderly without family oversight.

False Documentation – This encompasses a range of deceptive practices, including billing for procedures that were never performed, patients that were never seen, or home health care visits that never occurred.

Identifying and addressing Medicare fraud and abuse is crucial for the integrity of the Medicare program. Legal mechanisms and protections are in place to support whistleblowers in reporting suspected misconduct and helping ensure that Medicare funds are used appropriately for legitimate healthcare services.

Who Can Be a Medicare Whistleblower?

Medicare fraud is often discovered by people working inside healthcare organizations who see billing, treatment, documentation, or financial 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 qualifies.

Potential Medicare whistleblowers may include:

• Medical billers and coders
• Physicians and medical directors
• Nurses and nurse practitioners
• Physician assistants and medical assistants
• Compliance officers
• Revenue cycle and reimbursement personnel
• Hospital and health system employees
• Skilled nursing facility employees
• Home health and hospice employees
• Medicare Advantage plan employees
• Laboratory and pharmacy employees
• Durable medical equipment company employees
• Practice administrators and healthcare executives
• Contractors, consultants, and third-party vendors

A whistleblower does not necessarily need to be a physician or healthcare executive. Employees who understand how claims are generated, coded, documented, approved, or submitted to Medicare may be especially well positioned to recognize patterns that outsiders would not see.

How to Report Medicare Fraud

Reporting Medicare fraud is a critical step in safeguarding the integrity of healthcare services and ensuring that resources are allocated appropriately. If you suspect fraudulent activities, the following steps are crucial:

Gather Documentation – Collect or identify evidence related to the suspected fraud. This could include billing statements, emails, internal reports, or other documents that could substantiate your concerns. However, potential whistleblowers should be careful when accessing, copying, or removing employer records. Documents may contain confidential, privileged, or protected health information, and the legality of obtaining or retaining particular records can depend on the circumstances. Consider speaking with an attorney before taking documents that are not already lawfully in your possession.

Write a Detailed Memo – As soon as possible, document your observations and the specifics of the suspected fraud in a memo to yourself. Given that legal proceedings and investigations can extend over several years, this memo can serve as a vital record, preserving the accuracy of your recollections and observations. Include relevant dates, individuals involved, billing practices, claim information, and how you became aware of the suspected conduct when possible.

Compile a List of Relevant Documents – Make a list of any additional documents that could be pertinent to your case but are not currently in your possession. This could include internal records, billing information, or correspondence that you know exists but do not have direct access to. This list can guide investigators and legal representatives in their inquiry.

Contact a Medicare Fraud Attorney – Reach out to a law firm specializing in Medicare fraud. An attorney can evaluate whether the allegations may support a False Claims Act qui tam action or another type of report and explain the different procedures, deadlines, confidentiality considerations, and whistleblower protections that may apply.

Report to Government Authorities – Suspected Medicare fraud may be reported directly to the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). Medicare beneficiaries and others may also report suspected fraud through Medicare by calling 1-800-MEDICARE (1-800-633-4227) or using Medicare’s online fraud-reporting resources.

Reporting suspected fraud to an agency is not the same as filing a False Claims Act qui tam lawsuit. A potential qui tam case follows a separate federal court process, which is discussed below.

Consider Whistleblower Protections – If you are reporting fraud within your organization, consider the protections afforded to whistleblowers under federal and state laws. For example, the federal False Claims Act contains an anti-retaliation provision protecting certain employees, contractors, and agents who engage in lawful acts in furtherance of an FCA action or other efforts to stop violations of the Act. The protections available in a particular situation depend on the facts and applicable law.

By following these steps, you can play a crucial role in combating Medicare fraud, contributing to a more ethical and sustainable healthcare system. Because reporting options and legal rights can differ depending on the circumstances, individuals considering a whistleblower action may benefit from obtaining legal advice before deciding how to proceed.

Medicare Fraud Whistleblower Rewards

Whistleblowers play a vital role in exposing Medicare fraud. Under the federal False Claims Act, eligible private individuals with knowledge of fraud against the government may file a qui tam lawsuit on behalf of the United States.

It is vital to use an experienced Medicare fraud attorney to file this type of lawsuit. An individual who files a qui tam lawsuit is known as a “relator.”

If the government intervenes and proceeds with the case, a successful relator generally receives between 15% and 25% of the proceeds recovered through the lawsuit or settlement. If the government declines to intervene and the relator successfully pursues the case, the relator generally receives between 25% and 30% of the recovery. These amounts are subject to statutory exceptions and may be reduced in certain circumstances.

Of course, another point to consider is how do you know this illegal activity is happening? Has your employer forced you to be involved in any way? Considering these questions, if you know that Medicare or Medicaid fraud is happening where you work, contact a Medicare fraud attorney immediately.

Medicare Whistleblower Retaliation Protections

The False Claims Act includes protections for certain employees, contractors, and agents who face retaliation because of lawful actions taken in furtherance of a False Claims Act case or other lawful efforts to stop suspected violations of the Act.

Retaliation can include being fired, demoted, suspended, threatened, harassed, or otherwise discriminated against in the terms and conditions of employment because of protected whistleblower activity. Under 31 U.S.C. § 3730(h), qualifying whistleblowers may be entitled to remedies intended to make them whole. These can include:

• Reinstatement with the same seniority status
• Two times the amount of back pay
• Interest on back pay
• Compensation for certain special damages
• Litigation costs
• Reasonable attorneys’ fees

A False Claims Act retaliation claim generally must be brought within three years of the retaliatory act.

Not every workplace dispute or adverse employment action qualifies as unlawful retaliation. The protection depends on the employee’s conduct, the employer’s actions, and the connection between the two. Healthcare workers who believe they are being punished for raising concerns about Medicare fraud should consider speaking with an attorney promptly about their rights.

Medicare Fraud Cases

Medicare fraud enforcement actions and False Claims Act whistleblower cases can involve hundreds of millions of dollars in allegedly improper claims. Recent and notable examples include:

California Laboratory Fraud Scheme (2024) – The U.S. Department of Justice announced that a California man was sentenced to 10 years in prison after his laboratory billed Medicare approximately $234 million for laboratory tests while he was excluded from participating in federal healthcare programs. Medicare paid approximately $31.7 million on the claims. He was ordered to forfeit $31,761,286.21, including interests in two residential properties and one business property, and to pay the same amount in restitution.

Florida Cancer Genomic Testing Case (2024) – A Florida businessman and several companies agreed to pay more than $27 million to resolve False Claims Act allegations involving medically unnecessary cancer genomic tests and illegal kickbacks. The settlement resolved allegations brought in three whistleblower lawsuits. One relator, who had worked in billing operations for one of the laboratories, was eligible to receive up to $4.7 million, or 17% of the government’s recovery.

Durable Medical Equipment Whistleblower Case (2026) – In September 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, including braces, that was medically unnecessary and/or not properly prescribed. The case originated from a qui tam whistleblower lawsuit, and the relator was awarded 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 referrals of Medicare beneficiaries and submitted claims involving medically unnecessary back, shoulder, wrist, and knee braces.

Dr. Farid Fata Cancer Treatment Fraud Case – Michigan oncologist Dr. Farid Fata was sentenced to 45 years in federal prison in 2015 after pleading guilty to healthcare fraud and other offenses. According to the Department of Justice, his scheme involved administering medically unnecessary infusions or injections to 553 patients and submitting approximately $34 million in fraudulent claims to Medicare and private insurers.

How We Can Help

Our Medicare fraud attorneys play a crucial role in assisting whistleblowers in bringing to light fraudulent activities within the healthcare system.

We begin by thoroughly evaluating the details of the alleged fraud, leveraging our expertise in healthcare law to determine the viability of filing a whistleblower (qui tam) case under the False Claims Act. This preliminary assessment is vital in ensuring that the case has a solid foundation and meets the legal criteria for whistleblower actions.

Once a decision to proceed is made, our attorneys guide whistleblowers through the complex process of filing a qui tam lawsuit. This involves preparing the complaint and a written disclosure of substantially all material evidence and information the whistleblower possesses for the government. Under the False Claims Act, the complaint is initially filed under seal and is not served on the defendant until the court orders otherwise.

During this period, the government investigates the allegations and determines whether to intervene and take primary responsibility for the case or decline intervention, in which case the whistleblower may have the right to continue pursuing the action.

Our attorneys can represent and advise whistleblowers throughout this process, communicate with government attorneys and investigators when appropriate, and protect the whistleblower’s interests as the case develops.

Why Medicare Whistleblowers Choose Di Pietro Partners

Healthcare Fraud Experience From Multiple Perspectives
Di Pietro Partners represents whistleblowers in False Claims Act matters as well as healthcare providers in separate regulatory and litigation matters. This experience gives the firm insight into both the allegations raised by Medicare fraud whistleblowers and the billing practices, documentation, medical-necessity issues, and defenses that may become important as a case develops.

Firsthand Experience as a False Claims Act Relator
David also has firsthand experience with the whistleblower process. He previously served as a False Claims Act relator in a qui tam action involving 21st Century Oncology and Broward Health. That experience gives him a perspective few attorneys can claim: he has personally experienced what it means to step forward as a relator and participate in the federal qui tam process.

More Than 20 Years of Litigation and Trial Experience
Medicare False Claims Act cases are complex litigation. David has more than 20 years of litigation experience, has tried more than 70 jury trials, and has handled hundreds of bench trials and evidentiary hearings. His practice includes healthcare law, healthcare litigation, and whistleblower and qui tam matters.

Healthcare Leadership Experience
David previously served as Chairman of the North Broward Hospital District, commonly known as Broward Health. That leadership experience provided firsthand exposure to the operations and governance of a major public healthcare system, including healthcare compliance, physician relationships, risk management, and institutional decision-making.

Federal Government and Qui Tam Experience
The firm’s team includes a former U.S. Department of Justice attorney, adding federal-government experience to matters that may involve DOJ, U.S. Attorney’s Offices, HHS-OIG, CMS, and other federal agencies.

Medical Insight Within the Firm
Many Medicare fraud cases turn on medical questions: Was a service medically necessary? Does the documentation support the diagnosis? Does the treatment described in the medical record match what was billed to Medicare?

Dr. Tiffany Di Pietro serves as Medical Advisor to Di Pietro Partners. She is a licensed Florida physician and quadruple board-certified in Internal Medicine, Cardiology, Echocardiography, and Nuclear Cardiology. Her clinical background can provide the legal team with additional medical insight when evaluating medical records, diagnoses, treatment patterns, and medical-necessity issues in appropriate cases.

Nationwide Medicare Whistleblower Representation
Medicare is a federal program, and suspected Medicare fraud is not limited by Florida’s borders. Di Pietro Partners evaluates qualifying Medicare whistleblower matters nationwide, including cases involving false billing, medically unnecessary services, durable medical equipment, laboratory testing, Medicare Advantage risk adjustment, telehealth, kickbacks, and other alleged False Claims Act violations.

Contingency Fee Representation for Eligible Cases
Di Pietro Partners handles eligible False Claims Act whistleblower matters on a contingency-fee basis. For qualifying cases, attorney fees are generally contingent upon obtaining a recovery, subject to the terms of the firm’s written fee agreement.

Types of Medicare Fraud

Medicare fraud is one form of healthcare fraud and can take many forms, all sharing the common goal of improperly obtaining Medicare funds or benefits. Generally, fraudulent schemes involve knowingly or intentionally seeking improper Medicare payments through false claims, representations, documentation, or other deceptive conduct.

Some common types of Medicare fraud include:

Billing for Services Not Rendered: For example, a physical therapy practice may only provide massage therapy to patients. However, the therapist bills Medicare for ultrasound, traction, electrotherapy, ice, and heat. Each service has a code and cost involved. Thus, the therapist gets paid more for services not received by the patient. Knowingly billing Medicare for services that were never actually provided may constitute fraud.

Upcoding: Providers may commit fraud by knowingly using billing codes that represent a more expensive or higher-level service than was actually provided or supported by the medical record in order to obtain higher reimbursement.

Unnecessary Procedures: Knowingly billing Medicare for medically unnecessary services or procedures may constitute fraud when the applicable legal requirements are met. An improper or unnecessary service does not automatically establish fraud; the facts, including the provider’s knowledge and intent, matter.

False Documentation: Fraud may involve creating or altering records to support false Medicare claims, including documentation for procedures that were never performed, patients who were never treated, or home health visits that never occurred.

Kickbacks and Referrals: This involves knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce or reward referrals, purchases, orders, or recommendations involving items or services reimbursable by Medicare or another federal healthcare program. Certain arrangements may qualify for statutory exceptions or regulatory safe harbors.

Phantom Billing: This generally involves billing Medicare for services, procedures, supplies, or equipment that were never actually provided to the beneficiary. Billing for a more expensive service than was actually provided is generally considered upcoding, while knowingly billing multiple times for the same service may involve duplicate billing.

Upcoding of Patient Diagnosis: This can involve knowingly submitting diagnosis codes that make a beneficiary appear sicker than supported by the medical record in order to obtain higher reimbursement. This issue can be particularly significant in Medicare Advantage, where diagnosis information may affect a beneficiary’s risk score and the payments made by Medicare.

Prescription Fraud: Medicare fraud involving prescription drugs may include knowingly billing Medicare Part D for drugs that were never dispensed, submitting false prescription claims, or using kickbacks or other fraudulent arrangements to generate reimbursable prescriptions.

Identity Theft: Fraudsters may improperly use a beneficiary’s Medicare information or a healthcare provider’s billing credentials to obtain services or submit claims for services that were never provided.

Equipment Fraud: Durable medical equipment (DME) fraud may involve knowingly billing Medicare for equipment or supplies that were never delivered, were not ordered as represented, or were not medically necessary. Schemes may involve items such as braces, wheelchairs, diabetic supplies, or other DMEPOS products.

Medicare Fraud Red Flags Healthcare Employees May Notice

Healthcare employees are often in a unique position to recognize billing or treatment patterns that may not be visible to patients or outside investigators. A single unusual claim does not necessarily establish fraud, but repeated patterns or instructions that appear designed to generate improper Medicare payments can be warning signs.

Potential red flags may include:

• Billing for services, procedures, supplies, or equipment that employees know were never actually provided.
• Pressure to use higher-paying billing codes that are not supported by the medical record or the services performed.
• Diagnoses being added, exaggerated, or unsupported in order to increase Medicare Advantage risk scores or other Medicare payments.
• Repeated orders for tests, procedures, wound-care products, durable medical equipment, or other services that appear medically unnecessary.
• Bonuses, commissions, referral payments, or other financial incentives tied to the volume of Medicare-reimbursed services, tests, prescriptions, equipment, or patient referrals when those arrangements may improperly influence healthcare decisions.
• Medical records being altered, backdated, or created to support claims after services have already been billed.
• Patients being billed for services or equipment they did not request, receive, or need.
• Billing practices that do not match what physicians, nurses, billers, coders, or other employees actually observe occurring in the workplace.
• Pressure on employees to participate in, approve, or conceal questionable Medicare billing practices.
• Unusual changes involving admissions, discharges, insurance coverage, or payer status that appear designed to increase Medicare reimbursement rather than reflect a legitimate healthcare need.

These warning signs do not automatically mean Medicare fraud has occurred. Whether conduct violates the False Claims Act or another federal healthcare law depends on the specific facts, including what was billed, what Medicare required, and what the people involved knew or intended. Employees who repeatedly encounter suspicious practices may want to document what they observed and speak with a Medicare fraud attorney before taking further action.

Federal Medicare Fraud Laws

Federal Medicare fraud laws are designed to protect the integrity of the Medicare program by penalizing fraudulent activities that seek to deceive or misuse federal healthcare funds. These laws encompass a wide range of statutes and regulations, aimed at combating various forms of fraud and abuse within the Medicare system. Here’s an overview of some key federal laws related to Medicare fraud:

False Claims Act (FCA) – This act prohibits knowingly presenting, or causing to be presented, false or fraudulent claims for payment or approval by the federal government. Liability can also arise from knowingly using false records or statements material to a false claim and from certain other conduct covered by the statute. Under the FCA, individuals and companies can be held liable for false claims involving Medicare payments. The law also contains qui tam provisions allowing eligible private individuals to bring lawsuits on behalf of the United States and potentially receive a share of a successful recovery.

Anti-Kickback Statute (AKS) – The AKS makes it illegal to knowingly and willfully offer, pay, solicit, or receive remuneration to induce or reward referrals, purchases, orders, or recommendations involving items or services payable by a federal healthcare program, including Medicare. Certain arrangements may qualify for statutory exceptions or regulatory safe harbors.

Physician Self-Referral Law (Stark Law) – The Stark Law generally prohibits a physician from referring Medicare patients for certain “designated health services” to an entity with which the physician or an immediate family member has a financial relationship, unless an applicable exception is satisfied. It also generally prohibits the entity from billing Medicare for designated health services furnished as a result of a prohibited referral. Unlike the Anti-Kickback Statute, Stark liability does not depend on proving an intent to induce referrals.

Health Care Fraud Statute – This statute makes it a criminal offense to knowingly and willfully execute, or attempt to execute, a scheme to defraud a healthcare benefit program, or to obtain money or property from such a program through false or fraudulent pretenses, representations, or promises in connection with healthcare benefits, items, or services.

Violations of these laws can result in severe penalties, including fines, restitution, civil liability, exclusion from federal healthcare programs, and imprisonment when criminal statutes apply. The federal government, through agencies such as the Department of Health and Human Services Office of Inspector General (HHS-OIG) and the Department of Justice (DOJ), investigates and enforces healthcare fraud laws and works to recover improperly obtained government funds.

Medicare Fraud Categories

Medicare fraud can be categorized based on the different parts of the Medicare program, each addressing specific healthcare services and payments. Understanding these categories can help identify and report potential fraud more accurately.

Medicare Part A Fraud – Medicare Part A helps cover inpatient hospital care, skilled nursing facility care, hospice care, and certain home health services. Fraud involving Part A may include knowingly billing for services that were not provided, falsifying documentation to establish coverage or medical necessity, improperly increasing diagnosis-related group (DRG) payments, or submitting claims for medically unnecessary services.

Medicare Part B Fraud – Medicare Part B covers physician and other healthcare provider services, outpatient care, durable medical equipment, certain home health services, and many preventive services. Potential fraud may include billing for services or equipment never provided, upcoding, improper unbundling, falsifying records, or knowingly billing for medically unnecessary services.

Medicare Part C Fraud (Medicare Advantage) – Medicare Advantage allows beneficiaries to receive Medicare benefits through Medicare-approved private health plans. Because payments to Medicare Advantage organizations can be adjusted based in part on beneficiaries’ health status, fraud may involve knowingly submitting or causing the submission of unsupported or inaccurate diagnosis information that improperly increases risk scores and Medicare payments. Other potential schemes may involve false claims, kickbacks, or falsified records connected to Medicare Advantage services or payments.

Medicare Part D Fraud – Medicare Part D provides prescription drug coverage through private plans approved by Medicare. Fraud may include knowingly billing for prescriptions that were never dispensed, submitting claims for drugs different from those actually provided, using false prescription information, paying or receiving illegal kickbacks connected to federally reimbursed prescriptions, or otherwise submitting false claims for prescription drugs.

Each of these categories represents a unique aspect of Medicare, with fraudsters exploiting specific vulnerabilities to illicitly gain financial benefits. Reporting such activities is crucial in protecting the integrity of Medicare and ensuring that funds are used appropriately to benefit eligible recipients. If you suspect Medicare fraud, documenting what you know and consulting with a Medicare fraud attorney can help determine whether the conduct may support a government report or a False Claims Act whistleblower action.

Other Types of Healthcare Fraud

Besides Medicare fraud, the healthcare industry faces various other types of fraud that can significantly impact both the financial integrity of healthcare systems and patient care. These include:

Medicaid Fraud – Similar to Medicare fraud, Medicaid fraud may involve knowingly submitting false claims or other intentional schemes designed to obtain improper Medicaid payments. Fraudulent activities can include billing for services not rendered, upcoding, false documentation, illegal kickbacks, and knowingly billing for medically unnecessary services.

Private Insurance Fraud – This type of fraud involves knowingly submitting false or fraudulent claims to private health insurers. Tactics can include billing for services not provided, submitting duplicate claims, falsifying records, and performing or billing for unnecessary procedures as part of a fraudulent scheme.

Prescription Drug Fraud – Prescription drug fraud can involve various schemes, including billing for prescriptions that were never dispensed, falsifying prescription information, illegal kickback arrangements, and diversion or unlawful distribution of prescription medications. Fraud involving pharmaceutical companies may also involve conduct that causes false claims to be submitted to government healthcare programs.

Kickbacks and Referral Schemes – Illegal kickbacks may involve knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce or reward referrals, purchases, orders, or recommendations involving items or services payable by a federal healthcare program. Certain arrangements may qualify for statutory exceptions or regulatory safe harbors.

Provider Identity Theft – Fraudsters may use a healthcare provider’s identity or billing credentials to submit false claims for services never rendered or to facilitate other fraudulent billing schemes.

Upcoding and Unbundling – Upcoding involves billing for a more expensive service than was actually provided or supported by the documentation, while unbundling refers to improperly billing separately for services that should be billed together under an applicable bundled code or payment rule. When performed knowingly to obtain improper reimbursement, these practices may constitute healthcare fraud.

False or Exaggerated Claims for Disability Benefits – Knowingly making false statements or concealing material information to obtain or continue receiving disability benefits may constitute fraud. This can include misrepresenting one’s health condition, employment status, work activity, or income.

Addressing these types of healthcare fraud requires vigilant monitoring, strict enforcement of laws, and public awareness. Healthcare fraud not only drains resources but also can compromise patient care and increase healthcare costs.

Medicare Fraud FAQ

Q. How Long Do You Have to File a Medicare False Claims Act Case?
The False Claims Act contains its own statute of limitations. In general, an FCA action 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 when the conduct occurred and when the government learned of the material facts, potential Medicare whistleblowers should not assume they have the full 10 years to act. Anyone considering a qui tam case should speak with an attorney as early as possible so the relevant deadlines can be evaluated.

Q. What happens when you report Medicare fraud?
Once you report Medicare fraud, the relevant agency reviews the information to determine what action, if any, is appropriate. Not every report results in an investigation, and the agency may contact the person who submitted the report if additional information is needed. Depending on the circumstances, suspected Medicare fraud may lead to civil enforcement, administrative action, recovery of improperly paid funds, exclusion from federal healthcare programs, or criminal prosecution.

A False Claims Act qui tam lawsuit follows a different process. The lawsuit is initially filed under seal while the federal government investigates the allegations and decides whether to intervene.

Q. Where do you report Medicare fraud?
Medicare fraud can be reported directly to Medicare by calling 1-800-MEDICARE (1-800-633-4227) or through Medicare’s online fraud-reporting system. Suspected fraud, waste, or abuse involving Medicare may also be reported to the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), including through the OIG Hotline.

Individuals considering a False Claims Act whistleblower case should understand that filing a qui tam lawsuit is different from simply submitting a fraud report to Medicare or HHS-OIG. Consulting with a Medicare fraud attorney can help determine which option may be appropriate based on the circumstances.

Q. How do you report Medicare fraud anonymously?
HHS-OIG allows individuals to submit Medicare fraud complaints anonymously without providing identifying information. A person may also identify themselves to HHS-OIG while requesting confidentiality. However, HHS-OIG cautions that remaining anonymous may limit its ability to investigate or follow up on a complaint.

An anonymous hotline complaint is different from filing a False Claims Act qui tam lawsuit. Individuals considering a qui tam action should speak with an attorney before deciding how to report the suspected fraud because the legal procedures and confidentiality considerations are different.

Q. What are the penalties for Medicare fraud?
The penalties for Medicare fraud may be quite severe. Depending on the conduct and laws involved, consequences may include civil False Claims Act liability, monetary penalties, repayment or restitution, exclusion from participation in federal healthcare programs, and criminal fines or imprisonment. Not every Medicare billing error constitutes fraud, and the applicable penalties depend on the facts, the statute violated, and whether the matter is civil, criminal, or administrative.

Q. What is the cost of a Medicare fraud lawyer?
The cost of hiring a Medicare fraud lawyer can vary based on the attorney, firm, and type of matter. Di Pietro Partners handles eligible False Claims Act whistleblower cases on a contingency-fee basis. For qualifying cases, attorney fees are generally contingent upon obtaining a recovery, subject to the terms of the firm’s written fee agreement. This means qualifying whistleblowers generally do not pay hourly attorney fees as the case progresses.

Talk to a Medicare Fraud Attorney

Given the complexities and potential consequences of reporting Medicare fraud, consulting with a specialized Medicare fraud attorney can be an important step. Whether you’re a healthcare professional who has noticed questionable billing practices or another insider with firsthand knowledge of suspected fraud, your information may play a significant role in protecting Medicare funds and holding responsible parties accountable.

Di Pietro Partners represents Medicare fraud whistleblowers nationwide. Our team brings together healthcare law experience, more than 20 years of litigation experience, former federal government experience, public healthcare leadership, and physician-level medical insight. David Di Pietro has also personally served as a False Claims Act relator, giving him firsthand experience with the federal qui tam process from the whistleblower’s perspective.

Dr. Tiffany Di Pietro, a licensed Florida physician who is quadruple board-certified in Internal Medicine, Cardiology, Echocardiography, and Nuclear Cardiology, serves as the firm’s Medical Advisor. Her clinical background can provide additional insight in Medicare fraud cases involving medical necessity, diagnosis coding, treatment documentation, and other complex medical issues.

We understand the courage it takes to step forward and the importance of ensuring your rights and interests are protected throughout the process. That’s why we offer a confidential, no-obligation consultation to discuss your case and explore your legal options. Di Pietro Partners handles eligible Medicare False Claims Act whistleblower matters on a contingency-fee basis, meaning attorney fees are generally contingent upon obtaining a recovery, subject to the terms of the firm’s written fee agreement.

If you suspect Medicare fraud and are considering taking action, don’t navigate this challenging landscape alone. Contact Di Pietro Partners to confidentially discuss what you know, whether the conduct may support a False Claims Act claim, and the options available for reporting suspected Medicare fraud.