Lieff Cabraser Civil Justice Blog

How Whistleblowers Can Report and Stop Medicare and Healthcare Fraud


Whistleblowers continue to play a key role in ending fraudulent practices throughout the United States. A recent survey published by the National Whistleblower Center and conducted by PricewaterhouseCoopers found that 43% of corporate fraud was uncovered by whistleblowing related activities. When government funds are involved, whistleblowers play a critical role in protecting taxpayers. And, as the survey noted, the companies themselves are also better off in the long run by rooting out these bad practices.

Whistleblowers play an especially important role in identifying and stopping healthcare fraud, especially against the Medicare and Medicaid programs. Medicare and Medicaid fraud occurs whenever an individual or company misleads the government in an attempt to receive payment it does not deserve. Healthcare fraud takes many forms, but some of the most common are:

  • Billing for services that were not provided, medically unnecessary, or excessive.
  • "Upcoding" or "unbundling" claims, to make it appear that the provider did more work or more complicated work than it actually did.
  • Unnecessary inpatient admissions to increase reimbursement.
  • Failing to return overpayments to the government.
  • Offering compensation or kickbacks to other providers in order to get more referrals from those providers.

Fraud and systematic overcharging, the New York Times reports, are estimated at $60 billion, or 10 percent, of the Medicare program’s annual cost.

How to report fraud and abuse

Individuals may learn of suspected fraud in many different ways. Often, an employee of the provider may notice the misconduct. Likewise, the provider’s patients might notice suspicious charges on their bills.

If you are considering reporting suspected healthcare fraud, there are steps you should take to protect your rights.

  • Gather information about the false charges or claims. Depending on the type of fraud you suspect, there are different types of information you will need to present a viable case. Some basics include (a) the provider(s) involved, (b) example claims showing the improper charges, and (c) your explanation for why the claims were improper. Once again, a good attorney can help you navigate this process so that you are collecting information in an effective and appropriate manner.
  • Anyone suspecting Medicaid fraud, waste, or abuse is encouraged to report it. The first touch point should be the Program Integrity contact in the State Medicaid Agency for your individual state. This document includes contact information for the State Medicaid Agencies (SMA), and the Medicaid Fraud Control Units (MFCU). Another reporting option is to visit the Centers for Medicare & Medicaid Services’ State Contacts Database. You can also contact the Office of the Inspector General’s National Fraud Hotline at 1-800-HHS-TIPS (1-800-447-8477) or visit their website directly.
  • Alternatively, you are welcome to contact an experienced whistleblower attorney at Lieff Cabraser. There are statutes in place to encourage reporting fraud by rewarding the whistleblower. The same statutes often protect employees who report fraud from retaliation. A good attorney can guide you through this process so that your rights, both as an employee and as someone potentially entitled to a reward, are protected.

Employee whistleblowers may be concerned about retaliation by the employer. Fortunately, there are laws to protect you from retaliation, and a good lawyer can help you understand your options. You should also remember that whistleblower lawsuits are filed under seal and not shown to the defendant until the government has had a chance to investigate. Thus, for a period of time, only you, your attorneys, and the government will know about the lawsuit.

Whether making a report against a healthcare institution as a patient or employee, it is wise for those moving forward with a report of fraud to seek legal counsel. An experienced Medicare and health fraud whistleblower lawyer can prosecute the claim of fraud as well as protect your legal rights.

By Robert Nelson.