Medicaid Whistleblower Process
Learn About the Process for Exposing Medicaid Fraud Under the False Claims Act
Whistleblower Team Lead
Former DOJ Attorney
Whistleblower Team Lead
Whistleblower Team
Former U.S. Attorney and District Attorney
Medicare and Medicaid fraud are multi-billion-dollar problems. While the U.S. Department of Health and Human Services (HHS), U.S. Department of Justice (DOJ), and other arms of the federal government actively target fraud under government healthcare programs, they also rely heavily on whistleblowers to come forward.
If you have information about Medicaid fraud, you may be eligible to serve as a whistleblower under the False Claims Act. Whistleblowers who initiate False Claims Act cases involving Medicaid fraud are entitled to strong protections, and they are also entitled to financial rewards in some cases.
7 Steps to Expose Fraud Under the Medicaid Program
Exposing fraud under government programs like Medicare and Medicaid is a multi-step process. Whistleblowers must meet the applicable eligibility and filing requirements, and they must generally contact the federal government before exposing the fraud through other means. With this in mind, here is an overview of the seven major steps involved in filing a whistleblower lawsuit for Medicaid fraud:
1. Take Detailed Notes (Including Notes About Relevant Medical Records)
As a prospective Medicaid fraud whistleblower, your first step should be to take detailed notes about the fraudulent behavior in question. The False Claims Act prohibits healthcare providers and other entities from submitting any “false or fraudulent claims” for reimbursement under Medicaid. This encompasses all forms of fraud under the Medicaid system, including (but not limited to):
- Fraudulent healthcare billing practices involving any reimbursable Medicaid services
- Billing Medicaid for unnecessary medical procedures or unnecessary treatments
- Falsifying patient records or billing records in order to fraudulently bill Medicaid
- Recruiting Medicaid patients and paying (or receiving) illegal financial incentives for referrals
- Pharmaceutical fraud involving Medicaid billings for prescription medications
- Improperly billing Medicaid for administrative expenses and other non-covered costs
- Other fraudulent schemes resulting in improper receipt of taxpayer dollars
If you have information about any of these (or any other) forms of Medicaid fraud, you should write down as many details as possible. The more details you can provide to your whistleblower lawyer, the better.
2. Protect Any Relevant Records You Have in Your Possession
If you have copies of any records that are relevant to your Medicaid fraud allegations, you should keep these records in a safe place. This includes any patient records, billing records, or other documents you have taken from your employer’s facilities (if applicable), as well as any photos or videos you have taken with your phone.
If you don’t yet have documentation of the fraudulent activities in question, you should consult with a whistleblower lawyer before copying or removing any documents from your employer’s premises (if applicable). When reporting Medicare or Medicaid fraud as a whistleblower, you don’t necessarily need any specific form of documentation, and you do not want to do anything that could potentially put you in an untenable position.
3. Consult with a Healthcare Fraud Whistleblower Attorney
To help the federal government combat fraud and secure the legal protections that are available to whistleblowers under the False Claims Act, you will want to work closely with an experienced healthcare fraud whistleblower attorney throughout the process. While whistleblowers play a key role in the government’s ongoing fight against Medicare and Medicaid fraud, the protections (and compensation) afforded under federal law are only available to whistleblowers who come forward appropriately.
An experienced whistleblower attorney will be able to help you come forward appropriately if you are eligible to do so. As discussed below, in most cases, this involves filing a qui tam lawsuit under the False Claims Act in federal court.
4. Make an Informed Decision About Whether to Come Forward
After consulting with a whistleblower attorney, you should be able to make an informed decision about whether you are prepared to report fraud to the federal government. You may be ready to make a decision after your initial consultation or it may take more time—both of these are completely fine.
Making an informed decision is important because of the commitment involved in filing whistleblower claims related to fraud under Medicaid and other government healthcare programs. If you decide to come forward, you will need to be prepared to work closely with your attorney, who will work with the federal government on your behalf. The more information you can provide, the better the government’s chances will be of fully exposing Medicaid or Medicare fraud. Your level of involvement will also be a key factor in determining the amount of your whistleblower reward if your case leads to a successful enforcement action.
5. Work with Your Attorney to Prepare a Qui Tam Complaint
Taking a step back, if you decide to serve as a Medicaid whistleblower, this will most likely involve preparing a qui tam complaint under the False Claims Act. False Claims Act lawsuits are among the federal government’s primary means of recovering taxpayer dollars when healthcare providers bill Medicaid and other programs improperly.
Not only must your qui tam complaint meet the substantive requirements for initiating a False Claims Act lawsuit, but it must also meet the technical requirements for submission in federal district court. An attorney who has experience helping whistleblowers report violations of the False Claims Act will be able to assist with preparing and filing your claim appropriately.
6. Work with the Government During Its Investigation
After filing your qui tam complaint, you should be prepared to work with the government during its investigation. This may involve working with federal agents at the HHS Office of Inspector General (OIG), prosecutors at the DOJ, and law enforcement personnel at various other government agencies. As we said above, while HHS and the DOJ actively target entities in the healthcare system suspected of acting to defraud government programs, they rely heavily on whistleblowers to help them understand where they need to look.
From exposing reimbursement requests for medically unnecessary procedures to exposing forgery of Medicare and Medicaid patients’ records, whistleblowers can—and do—help the government prosecute all forms of fraud. By exposing Medicare fraud or Medicaid fraud through a qui tam complaint and then working with the government as it investigates your allegations, you can not only seek accountability for the fraud in question, but you can also help to deter future fraud throughout the entire healthcare system.
7. Claim Your Financial Reward if You Become Eligible
Finally, if your qui tam complaint leads to a successful enforcement action, you may be entitled to financial reward calculated as a percentage of the government’s recovery. This includes a percentage not only of any federal funds that were improperly disbursed, but also any civil or criminal monetary penalties.
Employees, former employees, citizen journalists, and other whistleblowers who come forward under the False Claims Act can all become eligible to receive rewards if their cases are successful. If you become eligible to receive a reward, your attorney can work with the government to secure your reward on your behalf.
Our Attorneys Represent Medicare and Medicaid Whistleblowers Nationwide
At Oberheiden P.C., we represent Medicare and Medicaid whistleblowers nationwide. We handle cases involving healthcare providers, pharmaceutical companies, medical device companies, nursing homes, child care centers, and all entities and individuals that fraudulently obtain funds under government healthcare benefit programs. We handle cases involving government procurement fraud and fraud under government contracts as well.
As a result of this experience, we are intimately familiar with the federal whistleblower process, the protections afforded to federal whistleblowers, and procedures for claiming whistleblower rewards. If you would like to speak with one of our attorneys, we strongly encourage you to schedule a free consultation today.
FAQs: Exposing Medicaid Fraud in the Healthcare Industry and Elsewhere
Can Managed Care Organizations Be Held Liable for Medicaid Fraud?
Yes. Like healthcare providers, managed care organizations (MCOs) can be held liable for Medicaid fraud. Liability may arise from a wide range of misconduct, including unlawful referral fees, improper financial relationships, false reporting, and other schemes involving Medicaid-funded healthcare services.
When managed care organizations submit false claims or cause false claims to be submitted to Medicaid, they may face civil penalties, treble damages, and other enforcement actions under federal and state False Claims Act statutes.
Can Federal Employees Serve as Medicaid Fraud Whistleblowers?
Federal employees can serve as Medicaid fraud whistleblowers; however, they generally must come forward under the Whistleblower Protection Act and the Whistleblower Protection Enhancement Act rather than the False Claims Act. These statutes protect federal employees against retaliation, including termination, demotion, and other adverse employment actions.
While federal employees who report fraud and abuse are typically not eligible for monetary whistleblower rewards, they are entitled to strong legal protections when they report misconduct through the proper channels.
How Do I Report Medicaid Fraud at a Daycare or Child Care Center?
The process for reporting Medicaid fraud at a daycare or child care center is generally the same as reporting fraud elsewhere in the federally funded healthcare system. To secure whistleblower protections and establish eligibility for potential monetary compensation, individuals must initiate the process by filing a qui tam lawsuit under the federal False Claims Act.
Our attorneys can evaluate the facts, determine whether the conduct qualifies as Medicaid fraud, and guide whistleblowers through each step of the reporting process.
Start the Process with a Free, No-Obligation Consultation Today
If you would like to know more about the Medicaid whistleblower process, we invite you to schedule a free, no-obligation consultation at Oberheiden P.C. To speak with one of our senior whistleblower attorneys in strict confidence as soon as possible, call 888-680-1745 or tell us how we can reach you online now.
