Medicaid Whistleblower

Learn What You Need to Know About Blowing the Whistle on Medicaid Fraud

Medicaid fraud costs U.S. taxpayers billions of dollars per year. While law enforcement personnel at the U.S. Department of Health and Human Services (DHHS) and U.S. Department of Justice (DOJ) do their best to uncover and prosecute Medicaid fraud, they also rely heavily on whistleblowers to come forward. If you think you may be able to serve as a Medicaid whistleblower, our attorneys can assist you with coming forward—including working with the DHHS or DOJ on your behalf.

While Medicaid fraud is common, it violates a host of federal laws and regulations. These include the False Claims Act, which prohibits healthcare providers, contractors, grant recipients, and other parties from submitting false and fraudulent claims for payment to the federal government. The False Claims Act also includes whistleblower provisions that provide protections—and potentially financial compensation—to individuals who expose fraud, waste, and abuse (FWA).

Understanding What Constitutes Medicaid Fraud, Waste, and Abuse

Like other types of fraud involving government healthcare programs, Medicaid fraud can take many different forms. Legitimate providers, bad actors, and other parties within the healthcare industry can all commit Medicaid fraud—and, when they do, they all deserve to be held accountable.

Not only that, but exposing Medicaid fraud can also help prevent other parties from committing fraud, waste, and abuse in the future. If parties know they can be held accountable, they are more likely to comply with the law. While complying with the Medicaid billing rules and regulations isn’t always easy, it is mandatory–and failure to do so can warrant allegations of health care fraud. There are steps that healthcare providers and other parties can—and should—take to avoid submitting fraudulent requests for reimbursement.

With this in mind, when should you consider serving as a Medicaid whistleblower? All of the following are common examples of Medicaid fraud, waste, and abuse:

Billing Medicaid for services that are not medically necessary
Billing Medicaid for supplies, equipment, and other items that are not medically necessary
Unbundling or upcoding services, supplies, equipment, or other items billed to Medicaid
Offering, soliciting, or accepting referral fees or other kickbacks unlawfully paid out of Medicaid-reimbursed funds
Diverting prescription medications or engaging in illegal drug marketing targeting Medicaid beneficiaries

Again, these are just some of the most common examples. From conspiring with others to improperly bill Medicaid to providing substandard services in clinics, nursing homes, and other facilities, healthcare fraud involving Medicaid can take many other forms as well. If you believe that you have (or may have) information about any form of fraud, waste, or abuse involving a Medicaid program or Medicaid beneficiaries, we strongly encourage you to speak with one of our whistleblower lawyers about possibly taking action.

Understanding Who Can Serve as a Medicaid Whistleblower

Are you eligible to join the ranks of Medicare and Medicaid whistleblowers? If you have access to non-public information about Medicaid or Medicare fraud, the answer is most likely, “Yes.” Individuals who can serve as Medicare and Medicaid whistleblowers under the False Claims Act include:

Federal employees who work for DHHS, the Centers for Medicare and Medicaid Services (CMS), and other federal departments, offices, and agencies
Employees of healthcare providers that bill Medicaid
Employees of clinics, nursing homes, dental offices, and other providers that bill Medicaid
Employees of pharmacies that bill Medicaid
Employees of other contractors and grant recipients that receive federal funds under Medicaid programs

Former employees are eligible to serve as Medicaid whistleblowers as well, as are many other individuals. Importantly, while the DHHS’s Office of Inspector General (OIG) only accepts whistleblower complaints from certain qualifying individuals, anyone who has information about federal fraud, waste, or abuse is generally eligible to submit a complaint under the False Claims Act to the DOJ.

Dr. Nick Oberheiden

Founder

Attorney-at-Law

Lynette S. Byrd

Former DOJ Trial Attorney

Partner

Brian J. Kuester

Former U.S. Attorney

Hon. Kevin McCarthy

55th Speaker, U.S. House of Representatives (ret.)

Government Consultant

Mike Pompeo

Of Counsel

Former U.S. Secretary of State

John W. Sellers

Former Senior DOJ Trial Attorney

Linda Julin McNamara

Federal Appeals Attorney

Nicholas B. Johnson

Former Prosecutor

Roger Bach

Former Special Agent (DOJ)

Chris J. Quick

Former Special Agent (FBI & IRS-CI)

Michael S. Koslow

Former Supervisory Special Agent (DOD-OIG)

Ray Yuen

Former Supervisory Special Agent (FBI)

How You Can Blow the Whistle on Medicaid Fraud

With this in mind, if you think you may be able to report fraud related to Medicaid, how do you serve as a whistleblower? Specifically, what do you need to do to ensure that you receive the whistleblower protections (and potentially the whistleblower compensation) that are available?

Here is a brief overview of the major steps in the process:

1. Consult with a Medicaid Whistleblower Lawyer

Your first step should be to consult with an experienced Medicaid whistleblower lawyer. There is a lot you need to know in order to make an informed decision about whether to come forward. An experienced lawyer will be able to determine if you are eligible to serve as a Medicaid whistleblower under the False Claims Act; and, if so, your lawyer will explain what you can expect throughout the process.

2. Determine Where You Should File Your Medicaid Whistleblower Complaint

If you decide to serve as a Medicaid whistleblower, one of the next steps will be to determine where you need to file your complaint. Generally, there are two possibilities: (i) filing a whistleblower complaint with the DHHS OIG; and, (ii) filing a qui tam complaint under the False Claims Act in federal court. If you need to file a qui tam complaint under the False Claims Act, the DOJ will handle the investigation of the information you bring forward.

3. Prepare Your Whistleblower Complaint and Supporting Documentation

Once you know where you need to file, then you (and your lawyer) can begin the process of preparing your whistleblower complaint and supporting documentation. To maximize the chances of the DHHS OIG or DOJ being able to use the information you disclose, it is important to ensure that you carefully follow all of the applicable substantive and procedural filing requirements.

4. Submit Your Whistleblower Complaint Through the Appropriate Channels

After preparing your whistleblower complaint, the next step is to come forward through the appropriate channels. The DHHS OIG has specific whistleblower complaint filing procedures, while filing a qui tam complaint under the False Claims Act involves submitting a formal pleading in federal district court. If you hire an experienced Medicaid whistleblower lawyer to represent you, your lawyer will handle this part of the process on your behalf.

5. Be Prepared to Work with the Government (Through Your Lawyer) During Its Investigation

Finally, once you submit your whistleblower complaint, you should be prepared to work with the government (through your lawyer) during its investigation. While the amount of additional information you provide is up to you, the more information you provide, the greater the chances are that your complaint will lead to a successful enforcement action. Cooperating during the government’s investigation can also increase the amount of your whistleblower reward if you become eligible to receive one.

FAQs: Serving as a Medicaid Fraud Whistleblower

How Do I Know if I Qualify as a Medicaid Fraud Whistleblower?

You may qualify as a Medicaid fraud whistleblower if you have non-public information about improper billings or reimbursement requests submitted to the federal government or a state agency. A whistleblower lawyer at Oberheiden P.C. can determine if you qualify; and, if so, your lawyer can help you make an informed decision about whether to come forward.

What Documentation Do I Need to File a Medicaid Fraud Whistleblower Complaint?

You do not need any specific type of documentation to report Medicaid fraud to the federal government. Billing records and internal communications are two common types of evidence in Medicaid fraud cases; however, evidence of fraud can take many other forms as well. When you speak with a lawyer at Oberheiden P.C. in confidence, your lawyer will be able to determine if you have sufficient documentation to serve as a Medicaid fraud whistleblower.

Will My Employer Find Out if I Blow the Whistle on Medicaid Fraud?

Whistleblowers who come forward under the False Claims Act are entitled to confidentiality. As a result, as long as you follow the requisite procedures, your employer shouldn’t find out that you blew the whistle. Importantly, even if your employer is able to discern your identity, it will be prohibited from retaliating against you under the Whistleblower Protection Enhancement Act or other applicable federal law—and it can face steep penalties if it retaliates unlawfully.

Am I Entitled to a Financial Reward if I Blow the Whistle on Medicaid Fraud?

Whistleblowers who report Medicaid fraud under the False Claims Act will be entitled to financial rewards in many cases. In successful False Claims Act cases, whistleblowers may be entitled to between 10% and 30% of the amount the federal government recovers.

Do I Need a Lawyer to Serve as a Medicaid Whistleblower?

While you are not legally required to hire a lawyer when blowing the whistle on Medicaid fraud, doing so is strongly recommended. An experienced lawyer will be able to help you meet all of the requirements for qualifying as a federal whistleblower and communicate with the government on your behalf. At Oberheiden P.C., we provide Medicaid whistleblower representation at no out-of-pocket cost.