Medicare Fraud Whistleblowers - Reporting And Compensation

By: Agnus Smith
Published: Wednesday, August 29 2018
Last Updated: 4 years ago

Medicare abuse and fraud is a rising concern. The federally run government healthcare program is particularly vulnerable given the sheer number of medical claims filed on behalf of beneficiaries. To top it all off, the opinion, shared by some in the healthcare industry, is that Medicare reimbursements are also too low. These factors have created an environment where providers seek to squeeze as much money out of their Medicare claims as possible, leading to questionable and sometimes illegal billing practices.

The Centers for Medicare & Medicaid Services (CMS) takes the issue seriously, and, thanks to the Affordable Care Act (ACA), has been provided with some new programs to help. This issue may not affect you directly, but even if you are not currently a Medicare beneficiary, you most likely will be at some point.

It is to everyone’s benefit to curtail fraudulent billing practices that raise costs for current and future Medicare recipients. The good news is that there are employees across the country willing to take action to help tackle Medicare abuses within their organizations, and they have the full backing of CMS. As a Medicare fraud whistleblower, the False Claims Act (FCA) often shields such employees from employer retaliation.

What Is A Medicare Fraud Whistleblower?

A Medicare fraud whistleblower is an employee of a healthcare organization that notices, tries to correct, and reports incidences of Medicare abuse in their workplace. Employees are uniquely placed within an organization to notice fraud, waste, dangerous practices, and general wrongdoing.

Example Of Medicare Abuses

Medicare fraud generally involves unethical and false billing practices. However, it can also include practices such as treatments or hospital admissions that are not considered medically necessary. This may mean your provider sends you for a test or keeps you overnight in the hospital, even though there is no need.

Under the fee-for-service model of billing prevalent in the US healthcare system, and particularly for beneficiaries with traditional Medicare coverage, providers make money based on the number of things (procedures, tests, etc.) they bill for, and not the outcome of treatment. This encourages providers to send patients for unnecessary treatments they can be reimbursed for.

On the billing side, Medicare abuse often means providers are billing procedures that never happened or supplies that weren’t ordered. This includes giving patients a more complex diagnosis than necessary, allowing the provider to order additional and more expensive tests. Another form of billing fraud includes billing Medicare for multiple days of a treatment when in reality they saw the patient on a single day.

Are Whistleblowers Protected?

The False Claims Act was designed to encourage whistleblowing, including Medicare whistleblower compensation, and acts to protect employees, such as a Medicare fraud whistleblower, from retaliation. In such cases, if you are fired or discriminated against by an employer for whistleblowing, legal action is possible.

To receive protection under the FCA, you must have proof of fraud and you must have proof you made an attempt to prevent or correct the Medicare abuse.

Spotting Medicare Fraud

Spotting Medicare fraud requires keeping a keen eye on billing practices and noting discrepancies between medical records and Medicare claims. Audits of the medical record and the billing claim would reveal any such inconsistencies. Sometimes the patients themselves may review claims and question charges for procedures they didn’t have or didn’t feel they needed.

How To Report It

If you believe you have knowledge of Medicare fraud, a smart first step is to contact a law firm that specializes in healthcare fraud. You can also initiate a fraud report on your own. You can contact Medicare directly at 1-800-MEDICARE, or the Office of the Inspector General at 1-800-HHS-TIPS. The Inspector General’s website also has an online submission form. Any reports you make as a Medicare fraud whistleblower are protected by the FCA.

Who Investigates Fraudulent Claims?

Once you have submitted a suspected case of Medicare fraud, the claim is reviewed by one of several CMS contractors. If the fraud is confirmed, it will be referred on to the Office of the Inspector General for a more thorough investigation and review. After a financial settlement has been reached with the provider, Medicare whistleblower compensation will be determined.

Rewards And Compensation

Medicare whistleblower compensation may include a significant portion of any settlement reached in the case. If the claim is made under the FCA by the whistleblower, acting on behalf of the government, the medicare whistleblower compensation may be in the neighborhood of 15-30% of the total settlement. Generally, there are hundreds or thousands of false charges involved in a whistleblower case, and these can add up to substantial sums of money, often numbering in the millions.