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Medicare Fraud FAQ

What records do I need to establish a case of Medicare Fraud?

Certain Courts require more detailed information than others. Some Courts require a specimen of an illegal billing from start to finish. For example, if you know the practice is billing for services not rendered, or upcoding, or performing unnecessary services then to establish that case you may need to show the billing records and medical records that patient John Doe is a Medicare recipient who came in for a knee contusion and after a brief examination the practice fraudulently billed Doe for everything any anything wholly unrelated to the visit. This creates a tension, as you are not authorized to take record you wouldn’t ordinarily have access to, but should make copies of records that you have access to that show the fraud. Please do not rely on this paragraph for anything. You should retain a qui tam lawyer before engaging in the process of record copying to ensure you are in compliance with the law.

Will I lose my job if I report Medicare Fraud?

The law has very rigorous mechanisms to prevent you from losing your job as a whistleblower under the False Claims Act for Medicare Fraud. But you must blow the whistle in the right way. Also, even though the company is not supposed to retaliate, it may illegally try to do so, it may conduct a mole hunt when they are alerted there is a whistleblower and may act in other unconscionable ways to make life more difficult.  

I think I’m being seriously overbilled by Doctor – can I be a whistleblower?

Anyone can be a whistleblower, but if you don’t have information regarding the extent of the activity and that the overbilling effecting your case isn’t just an errant mistake then you will most likely not be able to make a successful case. Rarely, these cases can be cobbled together through other intensive investigative techniques.

What’s the difference between the Stark Law and the Anti-Kickback Statute?

The Stark Law prohibits self-dealing. The Anti-Kickback Statute (AKS) prohibits paying referral fees or inducements for incoming business. For example, if a Doctor pays an illegal runner $50 per each patient referred to his practice that would violate the Anti-Kickback Statute. If the Doctor then went on to refer all the patients to a pharmacy in the building which he or she owns a piece of it is a violation of the Stark Law.

Do I need a whistleblower attorney to file a False Claims Act case over Medicare Fraud?

Yes. The Courts interpret the statute to mandate the use of a lawyer in filing a qui tam action under the FCA.  

Is it legal for a medical provider to refer patients to a facility that the provider has a direct interest in?

If a medical provider either directly or indirectly refers a patient to a facility in which they have a direct economic interest it is generally a violation of the Stark Act. Penalties under Stark include  recovery of payments, imposition of a $15,000 per service civil monetary penalty for knowing violations, and a monetary fine of $100,000 for each arrangement found to have willfully circumvented the statutory scheme.  In an effort to prohibit medical providers from not acting in the best interest of their patients this is often enforced as a strict liability offense.

Does it make a difference if I report the fraud to the government directly or file a Qui Tam under the False Claims Act?

Yes. It makes a world of economic difference to you. If you use the mechanisms within the False Claims Act, you are eligible to receive a False Claims Act (“FCA”) award up to 30% of the government’s recovery. If you report it directly without filing a whistleblower action, then you are not entitled to a portion of the qui tam recovery.

Whistleblower FAQ

What is the whistleblower program?

The whistleblower program is what people colloquially refer to as the various statutes such as the False Claims Act or the SEC Whistleblower programs that allow whistle blowers to bring an action. It is not like the Witness Protection Program, although the SEC whistleblowers may be able to remain anonymous, those filing False Claims Act cases, although initially under seal, will have their identity disclosed at some point.  The statutes entitle the successful prosecution of a case that is attributable to the whistleblower a portion of the recovery.

Do you get money for being a whistleblower?

Whistleblower stand to receive very bountiful whistleblower awards if their case is successful. Generally, under the False Claims Act, if the government intervenes it is around 20% with an average settlement of around $13 million dollars.  Of course, it’s a long process with precarious pitfalls that needs to be navigated to avoid the perils and maximize the chance of a successful result.

What is a whistleblower lawsuit?

A Whistleblower lawsuit that’s actionable generally falls into a few categories. A False Claims Act (FCA) in which the government has been defrauded.  SEC Whistleblowers where financial institutions fail to have the best interest of their clients in mind and practice.  Various state law protections, which often times only address wrongful termination, but certain states like New York, New Jersey, California, and Illinois may have stronger state whistleblower protections.

Who can be a whistleblower?

Theoretically, anyone can be a whistleblower who has information, but the law strongly favors whistleblower awards for those that have inside information. Under the False Claims Act (FCA), there is a growing body of law that suggests only an insider can recover, but there are some outlying opinions that discuss otherwise if there is very specific information provided. With an SEC Whistleblower, it can be anyone as well as long as they can provide insight to the global practice in which the financial company puts its own interests ahead of the consumers.

How do you file a qui tam lawsuit? How do I file a qui tam lawsuit?

A Qui Tam Lawsuit, also known as a whistleblower lawsuit is generally filed pursuant to the False Claims Act (FCA), which requires the use of an attorney. The case must be filed under seal with proper notice given to the various government agencies on behalf of the whistleblower, also known as a relator.