Medicaid Whistleblowers: Answering Common Questions About Reporting Medicaid Fraud
What Potential Healthcare Whistleblowers Should Know About Reporting Fraud
In the United States, healthcare fraud is big business.
According to the Department of Justice, the United States government obtained more than $3 billion in fraud settlements in 2019.
Approximately $2.6 billion of that amount came from fraud involving the healthcare industry.
Recoveries of this magnitude are possible because of whistleblowers who disclose to the government their knowledge of fraud in the healthcare industry. In 2019, cases brought by whistleblowers accounted for 70 percent of the total amount the Department of Justice recovered in fraud settlements.
Whistleblower reward laws offer whistleblowers the chance to share in any funds recovered as a result of a government investigation or lawsuit. The most important of those laws is the False Claims Act, which allows whistleblowers to report fraud and misconduct in government contracts and programs. Under the False Claims Act, whistleblowers, known as relators, can bring what are called qui tam lawsuits on the government’s behalf, with the promise of a potential reward of a portion of the government’s recovery (between 15% and 30%).
In 2019 alone, whistleblowers received a combined $265 million in rewards from the federal government for exposing fraud that would otherwise go undetected.
Get answers to 9 common Medicaid whistleblower questions
In this post, our experienced whistleblower attorneys have answered 9 of the most important questions posed by individuals who have knowledge of potential fraud in the Medicaid program. Click the links below to jump to a specific question:
- What is Medicaid?
- What is Medicaid Fraud?
- What Types of Medicaid Fraud Are Commonly Reported?
- How Do I Become a Medicaid Fraud Whistleblower?
- How to Report Medicaid Fraud
- Is There a Reward for Reporting Medicaid Fraud?
- How Does Whistleblower Law Prevent Medicaid Fraud and Abuse?
- Are There Legal Protections for Medicaid Whistleblowers?
- Is There a Deadline to File a Medicaid Fraud Lawsuit?
What is Medicaid?
Medicaid is a public healthcare program in the United States that covers medical expenses for low-income and disabled people.
Funding for Medicaid is shared between the Federal Government and states participating in the program. In terms of spending, nursing home care is the fastest growing part of the Medicaid program, followed by homecare and other healthcare services provided to elderly and infirm people.
Experts expect the growth in Medicaid spending to continue as the Baby Boomer generation ages.
What Is Medicaid Fraud?
Healthcare providers that bill Medicaid are required to follow certain laws and regulations.
When they knowingly fail to follow those rules and obtain payments from Medicaid, they cheat the system.
In addition to Medicaid, other federal and state healthcare programs—like Medicare, Tricare, and healthcare services paid for by the Veterans Administration—are common targets for healthcare fraud.
Healthcare fraud may be perpetrated by many actors in the healthcare system, including providers (doctors and clinics), hospitals, nursing homes, home health agencies, pharmaceutical manufacturers and pharmacies, labs, managed care organizations, and others.
Reporting Medicaid fraud is important because it helps the government recover money that could be spent elsewhere on legitimate healthcare services for those who need it most.
What Types of Medicaid Fraud Are Commonly Reported?
There are many ways a healthcare provider can defraud the Medicaid program. Common Medicaid fraud schemes committed by providers include:
- Falsifying a diagnosis, providing medically unnecessary services, or ordering excessive tests;
- “Upcoding” or billing for services that were not performed;
- Billing multiple times for one service;
- Prescribing unnecessary medications;
- Making false statements about covered services;
- Prescribing drugs for use by someone other than the patient; and
- Taking “kickback” payments for patient or service referrals.
Keep in mind that insurers can also engage in Medicaid fraud. Overstating the cost of a service, making misleading statements about the benefits of a healthcare plan, or denying valid claims are all ways an insurance company may commit Medicaid fraud.
How Do I Become a Medicaid Fraud Whistleblower?
The False Claims Act is a federal law that allows anyone with knowledge of Medicaid fraud to “blow the whistle” on the fraud. The Act allows whistleblowers to bring a lawsuit on behalf of the government against the fraudster. The whistleblower, known as the “relator,” may be entitled to a substantial reward.
How to Report Medicaid Fraud
If you think you have a whistleblower case, the first thing you should do is contact a Medicaid fraud lawyer. Qui tam actions under the False Claims Act involve complicated procedures and rules. Importantly, a qui tam action generally can be based only on non-public information. You must also file your action quickly, before another Medicaid fraud whistleblower files a case alleging the same misconduct under the False Claims Act.
Hiring a Medicaid fraud lawyer is the best way to ensure that you receive a reward for coming forward. Our attorneys at Constantine Cannon have extensive experience helping Medicaid whistleblowers file lawsuits under the False Claims Act and obtain whistleblower awards.
Is There a Reward for Reporting Medicaid Fraud?
Yes, there may be a sizable Medicaid whistleblower reward for reporting Medicare or Medicaid fraud.
The False Claims Act authorizes a relator to receive between 15% and 30% of the total amount recovered by the government. For example, if the government recovers $250 million from a fraudster, the Act may entitle you to between $37.5 million and $75 million.
Whether you are entitled to the reward and how large the reward will be depends on several factors. During the course of an investigation for fraud under the False Claims Act, the government may require your assistance in building the case. Cooperation with these efforts, along with the depth and quality of the information you can provide at the outset of the case, are all factors that influence your Medicaid whistleblower reward amount.
A Medicaid whistleblower attorney familiar with qui tam actions and government negotiation plays a large role in your reward as well. An experienced Medicaid fraud lawyer can help you get the maximum reward for your help.
How Does Whistleblower Law Prevent Medicaid Fraud and Abuse?
Like many other laws, the False Claims Act and various state whistleblower laws work to prevent Medicaid fraud and abuse by imposing penalties on anyone who commits healthcare fraud.
The False Claims Act allows the government to recover damages equal to three times the losses it sustains. The False Claims Act also imposes a penalty for each violation, which currently is between $11,665 and $23,331 per violation. While this number may seem small, damages for a large number of violations can easily reach millions of dollars.
But perhaps most importantly, the False Claims Act and other whistleblower laws deter fraud by allowing people who are often closely associated with the fraud to bring whistleblower claims. Employees of pharmaceutical companies, hospitals, doctor’s offices, or insurance companies may have first-hand knowledge of their employer’s fraudulent activity. Much of this activity would go unnoticed and unpunished if not for the valuable service whistleblowers provide. By making whistleblower rewards up to 30% of the settlement recovered, the government creates an incentive to come forward. Since any employee could be a whistleblower, the power to bring qui tam actions makes the False Claims Act a valuable tool in fighting Medicaid fraud.
Are There Legal Protections for Medicaid Whistleblowers?
Because of the kinds of information needed to bring a successful Medicaid fraud claim, whistleblowers are usually employees closely related to the fraudulent activity.
The False Claims Act accounts for this by providing protections against retaliation.
This section of the Act protects employees from termination or discrimination based on their decision to expose the fraudulent activity. If you experience termination, harassment, or other discrimination, the Act allows recovery of back pay, litigation costs and attorney fees, and even reinstatement. In addition, many states have their own employment laws covering wrongful termination and workplace harassment.
Nevertheless, whistleblowers may still suffer discrimination and harassment as a result of their decision to report Medicaid fraud or abuse. Constantine Cannon’s attorneys understand this and will work with you to protect your reputation and minimize the fallout from blowing the whistle.
Is There a Deadline to File a Medicaid Fraud Lawsuit?
Lawsuits under the False Claims Act are subject to two important deadlines. The first is the Act’s statute of limitations. Under this limit, whistleblowers must report Medicaid fraud or abuse within six years of the false claim constituting the fraud. This period may be only three years if the government knew or should have known about the fraud but took no action.
The second deadline is the “first to file” rule, which is important to follow for your reward claim. The False Claims Act authorizes only the first relator to report the fraud to continue with the lawsuit. Being second in line means you likely will have no right to make a claim and no right to any reward. Accordingly, contacting a Medicaid fraud lawyer and filing your lawsuit as soon as possible is a must to ensure you receive a reward.
Contact a Medicaid Fraud Whistleblower Lawyer
Because of the profound effect it may have on your job and your life, deciding to blow the whistle on Medicaid fraud is a big decision and an important one.
Whistleblowers are the main way Medicaid fraud is discovered and continue to serve a crucial role in exposing it. At Constantine Cannon, our team of attorneys has helped recover over $350 million in whistleblower rewards.
Contact us today for a confidential case review to see if you have a whistleblower claim.