Medicare fraud costs taxpayers billions of dollars each year and can take many forms, from billing for services never provided to upcoding procedures or paying kickbacks for referrals. If you work in healthcare, or if you are a patient or family member who has witnessed suspicious billing, you may be wondering what you can do. The law provides a specific path for private citizens to report fraud and share in any money recovered. Here is what you should know about your rights.
What Is a Whistleblower Under the False Claims Act?
The federal False Claims Act (31 U.S.C. 3729-3733) allows private individuals, called relators, to file a lawsuit on behalf of the government. This type of case is known as a qui tam action. The relator does not need to be a lawyer or an insider; patients, family members, and healthcare workers have all filed such cases. The government reviews the case and decides whether to join (intervene) or let the relator proceed alone.
How Much Can a Whistleblower Receive?
If the government recovers money as a result of the case, the relator generally receives a share of the recovery. When the government intervenes, the relator typically receives 15 to 25 percent of the amount recovered. If the government does not intervene and the relator pursues the case successfully on their own, the share is generally 25 to 30 percent. The exact percentage depends on factors such as how much the relator contributed to the case.
What Penalties Can Fraudulent Parties Face?
Those found liable under the False Claims Act can owe up to three times the government's damages, plus additional civil penalties for each false claim submitted. These per-claim penalties are adjusted for inflation each year, so the exact amount changes over time. The prospect of treble damages and per-claim penalties is what makes these cases significant even when individual claims appear small.
Confidentiality and Deadlines
Qui tam complaints are filed under seal, meaning they are kept confidential while the government investigates. This protects the relator from early disclosure of their identity. It is important to act promptly, however. The general deadline to file is six years from the date of the violation, or three years from when the government knew or should have known about it, but in no case more than ten years after the violation.
Protection From Retaliation
Fear of losing your job should not stop you from reporting fraud. Section 3730(h) of the False Claims Act protects employees from retaliation for actions taken to stop a violation. If you are fired, demoted, harassed, or otherwise discriminated against because of your whistleblowing, you may be entitled to remedies such as reinstatement and double back pay, plus other relief.
How to Report Medicare Fraud
You do not have to file a lawsuit to report suspected fraud. You can report concerns 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 suspect fraud, waste, or abuse can also call 1-800-MEDICARE. Reporting through these channels is confidential, and you do not need to have proof of fraud to make a report; a reasonable suspicion based on what you have seen is enough to start the process.
Practical Steps to Consider
- Document what you observed, including dates, services, and any billing codes or paperwork you have access to.
- Keep copies of any relevant records in a safe place outside your workplace if you are an employee.
- Report promptly, since the statute of limitations can limit your ability to recover.
- Understand that filing a qui tam case is a serious legal step; many relators consult with an attorney experienced in False Claims Act matters before filing.
Whistleblowers play a vital role in protecting the Medicare program for everyone who relies on it. Understanding your rights is the first step toward deciding whether and how to come forward.
