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How to Report Medicare Fraud

Categories: Health Care Law

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Identifying Fraud

Medicare Fraud is extremely complex and can require the help of experienced and knowledgeable attorneys. In order to stop acts of Medicare fraud against the government, whistleblowers may bring a civil lawsuit under the False Claims Act. Any person or entity that has encountered fraud against federal programs or contracts can serve as a whistleblower. The type of lawsuit that a whistleblower may bring is called a qui tam. In a qui tam lawsuit, the person who is pursuing the claim is doing so on behalf of the government. This person is referred to as a “relator”. In essence, the relator is helping the government eliminate waste, fraud and abuse by coming forward. Many times there is a financial reward for the relator in a successful qui tam lawsuit. If you have encountered fraud, you should consult an attorney who may advise you to institute a quit tam lawsuit.

Selecting the right qui tam attorney is essential for a successful outcome. Factors to consider when choosing the right qui tam attorney include:

  • Experience in qui tam and other Medicare Fraud related cases
  • The attorney’s resources
  • Experience and familiarity regarding which whistleblower cases the government will prioritize and pursue
  • An understanding of the risks involved

Qui Tam Explained

The Federal False Claims Act is a federal law that imposes liability on persons and entities that defraud governmental Medicare and Medicaid programs. The False Claims Act is the government’s primary tool in counteracting fraud. For instance, as of 2012, over 70% of all False Claim actions were initiated by whistleblowers. Between 1987 and 2013, $27.2 billion dollars were recovered in qui tam cases brought by whistleblowers. In 2014 alone, over 700 False Claims actions were brought by whistleblowers.

Under the False Claims Act, any Medicare payment associated with illegal activity or noncompliance with federal regulations could be considered Medicare Fraud. While there are many different types of Medicare Fraud, a common factor of each type is that the fraud has attempted to collect money from a government payor illegitimately. Acts that may constitute fraud include, but are not limited to:

  • Billing Medicare for a good or service that is not medically necessary
  • Billing Medicare in a way that does not accurately reflect the goods or services provided
  • Billing Medicare for goods or services not rendered
  • Noncompliance with FDA regulations
  • Violations of the Anti-Kickback Statute
  • Violations of the Stark Law
  • Improper or noncompliant documentation of personal information

Whistleblowers may report fraud under the qui tam provision to the False Claims Act. In qui tam lawsuits, the government may find cause to intervene and join the lawsuit. And, if the government is successful in recovering damages, the whistleblower is entitled to up to 25% of what the government recovers.

In deciding whether to pursue a qui tam case, a whistleblower should consider:

  • The likelihood the defendant will be liable for a substantial judgment
  • Liability under the False Claims Act
  • The harm to the government
  • The ability of the whistleblower to pursue the lawsuit
  • The risks involved with filing suit

It is also important to realize that the False Claims Act prohibits:

  • Knowingly presenting, or causing to be presented a false claim for payment or approval
  • Knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim
  • Conspiring to commit any violation of the False Claims Act
  • Falsely certifying the type or amount of property to be used by the Government
  • Certifying receipt of property on a document without verifying that the information is true
  • Knowingly buying Government property from an unauthorized officer of the Government and
  • Knowingly making, using, or causing to be made or used a false record to avoid or decrease an obligation to pay or transmit property to the Government

For these prohibited acts, the False Claims Act imposes liability for treble damages and a civil penalty ranging from $5,000 to $10,000 per claim for anyone who knowingly submits or causes the submission of a false or fraudulent claim (treble damages are a multiple of, and not an addition to, actual damages). Nonetheless, certain claims are also not actionable. These concerns should be addressed with an attorney.

How We Can Help You

The attorneys at Oberheiden & McMurrey, LLP have detailed knowledge and experience with qui tam lawsuits. A qui tam lawsuit must be filed under seal in federal district court in accordance with the Federal Rules of Civil Procedure. This may pose complications, and potentially harm any persons pursuing a claim without counsel.

With many years of prosecutorial experience in Medicare Fraud and with qui tam lawsuits, the attorneys at Oberheiden & McMurrey, LLP are well equipped to guide you in your qui tam lawsuit. Several of our attorneys were former federal prosecutors for the United States Attorney’s Office. As former prosecutors, they are intimately familiar with the procedures of the federal legal system as well as the evidentiary requirements that are necessary for a successful whistleblower claim.

Our attorneys have worked extensively with the Office of Inspector General, the Department of Health and Human Services, the Federal Bureau of Investigation, and other federal law enforcement agencies. Our attorneys’ knowledge and experience can help clients present their claims properly to the government and increase the likelihood of a successful outcome.

Contact Oberheiden & McMurrey, LLP

Speak with the team at Oberheiden & McMurrey, LLP today. Let us review your case, free and confidential. Contact us today.

Disclaimer

This message may constitute attorney advertising in some jurisdictions. Prior results do not guarantee similar outcomes. This message is meant to be informative and does not establish an attorney-client relationship between Oberheiden & McMurrey, LLP and the reader.

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