Medicare fraud costs taxpayers billions of dollars each year. It can take many forms, from billing for services never provided to upcoding procedures to receive higher payments. When someone inside a healthcare organization or a patient or family member sees this happening, they may wonder what they can do. One of the most powerful tools available is the federal whistleblower process, which allows private citizens to help the government recover misspent funds.
What Is a Whistleblower Scheme?
In the Medicare context, a whistleblower scheme refers to the legal framework that lets private individuals, known as relators, file a lawsuit on behalf of the government. This is called a qui tam action, and it is authorized by the federal False Claims Act (31 U.S.C. 3729-3733). The law is designed to encourage people with inside knowledge of fraud to come forward by offering them a share of any money recovered.
Common examples of conduct that can trigger a whistleblower case include:
- Billing Medicare for services, tests, or equipment that were never provided.
- Misrepresenting the level of service provided to receive a higher payment.
- Submitting claims for medically unnecessary procedures.
- Paying kickbacks to physicians or others in exchange for patient referrals.
- Falsifying patient records to support fraudulent claims.
How the Process Works
When a relator files a qui tam complaint, the case is filed under seal. This means it is kept confidential for a period of time while the government investigates. The U.S. Department of Justice and agencies such as the HHS Office of Inspector General review the allegations to decide whether to intervene and take over the case.
If the government intervenes and the case is successful, the relator generally receives between 15 and 25 percent of the recovery. If the government declines to intervene and the relator pursues the case on their own, the relator's share rises to between 25 and 30 percent. Parties found liable can be required to pay up to three times the government's damages, plus per-claim civil penalties that are adjusted for inflation each year.
Deadlines and Protections
There are strict time limits for filing a qui tam case. In general, a claim must be filed within six years of the violation. Alternatively, it can be filed within three years of when the government knew or should have known about the fraud, but in no event more than ten years after the violation. Because of these deadlines, anyone considering action should not delay in seeking guidance.
Whistleblowers also have legal protection from retaliation. Under 31 U.S.C. 3730(h), an employer cannot fire, demote, harass, or discriminate against an employee because they took steps to stop fraud or assisted in a case. Remedies for retaliation can include reinstatement and double back pay, along with other damages.
How to Report Suspected Fraud
Not every concern requires a lawsuit. Anyone who suspects Medicare fraud can report it directly to the government. Tips can be submitted to the HHS-OIG hotline at 1-800-HHS-TIPS (1-800-447-8477). Medicare beneficiaries who believe they have been billed improperly can call 1-800-MEDICARE for assistance.
Patients, families, and healthcare workers all play a role in protecting the Medicare program. Understanding how the whistleblower process works, what the deadlines are, and what protections exist can help people make informed decisions about whether to come forward. Anyone considering filing a qui tam case should be aware that the process is complex and that legal representation is typically necessary, but the law exists precisely to reward those who help expose fraud against the government.
