How to Report Healthcare Fraud Confidentially: Safely Blow The Whistle On Abuse

The Department of Justice estimates Healthcare Fraud costs the American taxpayers an estimated $100 Billion dollars a year. Medicare, Medicaid and Tricare are massive Federal (public) health programs.

These massive programs are prime targets for unscrupulous and dishonest Medical Care providers. Waste, fraud and abuse are some of the methods they use to defraud and cheat taxpayers. The result is a major burden on the programs, taxpayers and patients.

Rising healthcare costs and inaccurate medical records are a direct result.

Medicare, Medicaid and Tricare are Federally funded health programs. Public programs fall under the protection of the Federal False Claims Act (FCA).

Knowingly making false claims to these public programs for medical treatments, services or drugs is illegal.

The FCA has a qui tam section allowing individuals to report wrongdoing. Whistleblowers who come forward receive legal protections and may qualify for financial bounties when they uncover abuse which results in financial recovery.

Medicare Fraud is a crime. Those responsible face severe financial penalties and incarceration. Doctors, Insurers, Hospitals, Hospice, Rehabilitation Clinics and Pharmaceutical companies have all been found guilty of Medicare, Medicaid and Tricare fraud.

Who reports Medicare Fraud?

Some people think patient’s are the only people reporting Medicare fraud.

Patients should inform when something is wrong but medical professionals are in the best position to have knowledge of and report Medicare Fraud. Doctors, Specialists, Administrators, Nurses, Pharmacist or any medical employee can report.

Working in the healthcare system provides them an insider’s knowledge of the right and wrong way treat patients and seek reimbursements for care.

Their access and knowledge of fraud puts them in the ideal position to report on an uncovered pattern of abuse. When abuse, fraud or misuse fact patterns emerge they have an ethical responsibility to report it and help stop the illegal conduct from continuing.

The Government knows it can be risky do the right thing by reporting dishonest, fraudulent Medical behavior. This is why they allow people to report suspicious activity anonymously. There are two ways to privately report conduct to Medicare or the Inspector general.

• Calling - 1- 800-Medicare or 1-800-HHS-TIPS
• Online Form submission (Link)

List of information to have ready:

• Medical Providers name and ID number
• Service, prescription or treatment and ID Number
• Date of service, treatment or product that was received of delivered
• Payment approved and paid for Medicare Date on Medicare
• Summary Notice (MSN)
• Your name and Medicare number
• Reason why Medicare should not have reimbursed medical providers
• Any other information (evidence) you have about why Medicare should not have paid

Reporting Medicare fraud does offer up to a $1000 reward to eligible claims. Five conditions are necessary for a reward to be paid.

1. You must report your personal Medicare fraud. Allegations need to be specific and not generalized.
2. Suspected Medicare fraud must be confirmed as potential fraud by a Medicare contractor responsible for investigating fraud or abuse. The case must then be formally referred to the Office of the Inspector General for investigation.
3. You must not be a participant in the fraudulent act or are qualified for another claim reward for the same offenses.
4. The person or organization must not currently be under investigation for the same offense
5. Your report must lead to the recovery of at least $100.

The reward is based on a percentage of 10% of the recovered sum up to a maximum of $1,000. Whichever amount is less. If more than one person is eligible for a reward it is split between them.

Another option for individuals is submitting a claim using the False Claims Act. The FCA provides rewards and protection for people who report fraud against any Federal Government program. Civil health care programs are covered under the FCA. Importantly for those making a claim is the FCA’s qui tam provision. This provides rewards and protection for relators of fraudulent acts who bring civil action on behalf of the state or federal government. Also known as qui tam whistleblowers.

Whistleblowers will file an action (lawsuit) against the party responsible for the fraud. This copy of the action needs to be officially submitted to the Office of the Inspector general and the U.S. Attorney.

When an FCA Claim is filed it is sealed by the U.S. Circuit Court. The Whistleblower’s identity will remain anonymous as the Government investigates the validity of the claimants accusations. This should only take 60 days but could take longer if the Government needs more time.

The U.S. Attorney’s Office will complete their review of the case and decide whether or not to assist in the prosecution of the case. If they decide to assist, the whistleblower’s reward will be reduced to 15%-25% of the total recovery - but the weight and resources of the government are brought into the investigation. If the Government decides against further action, plaintiffs can still proceed on their own.

The whistleblower reward from a stand alone action is 25%-30% of the recovered sum.

Remaining an anonymous whistleblower may not be possible once the case is unsealed and made public. However, the False Claims Act provides protection to people who blow the whistle on healthcare fraud via the Department of Labor and the Department of Justice.

At any point in the FCA process legal counsel can be retained. Finding a qui tam lawyer with experience in healthcare fraud and FCA claims is recommended. Lawyers will consult on these type of cases for free and work on a contingency basis pending the strength of the case.