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How to Report Medicare Fraud

An Introduction to Reporting Medicare Fraud

Fraud is a serious problem that robs Medicare of hundreds of millions of dollars every year. Reducing this fraud is no simple matter. Medicare is the largest health program in the United States, and it generates more transactions annually than can be reasonably investigated for fraud.

In order to detect and prosecute this fraud, the US is highly dependent upon whistleblowers who are willing to report Medicare fraud and provide the evidence necessary to bring cases forward. To encourage whistleblowing, the US relies on a law known as the False Claims Act (FCA).

How the FCA is Used in Medicare Fraud Cases

The FCA is a law with more than 100 years of history that has been used to go after those who submit false claims and reports to federal programs. It is called the Lincoln law because it was passed by Abraham Lincoln to allow for the more effective prosecution of war profiteers who were defrauding the Union Army.

One of the key features of the FCA, even in its earliest version, is a qui tam provision that allows anyone with knowledge of fraud to file on behalf of the government and collect a share of any funds that are recovered from those prosecuted for fraud. These awards have been worth millions of dollars in recent history.

Today, Medicare is one of the largest public programs, so it is also one of the programs most frequently targeted by fraud. If you have knowledge of fraud, you may be able to report that fraud, and file on behalf of the government to claim a percentage of what is recovered.

In the following sections, you’ll learn how to spot Medicare fraud as a patient or an employee of a provider, what information you need to collect a report, and how you should begin the process of reporting fraud.

How to Spot Medicare Fraud as a Patient

Most types of Medicare fraud involve services that are billed to the program and either not provided to the patient or provided to the patient without an adequate medical reason. Certain types of fraud may be committed right in front of the patient, with the expectation that they will not understand the law well enough to realize what is happening.

Patients can play an important role in detecting fraud by watching for the following warning signs or improper practices. You may be witnessing fraud if you…

  • Are told that you can reduce your out-of-pocket costs by agreeing to more tests
  • Receive telemarketing calls or door-to-door visitors who attempt to convince you to request prescriptions, implants or medical procedures
  • Are offered gifts if you agree to request drugs or services from your doctor
  • Routinely receive bills for copays or records of waived copays even though the service is covered under your plan with no copay
  • Receive instructions about how to get Medicare to cover services that are not part of your plan
  • Are told that Medicare endorses a specific product or service

If you notice any of these warning signs, begin creating documentation of them as soon as you can. Preserve invoices, notices, electronic communications and any other records that may be helpful. Look for a full list of the information you should preserve in the following section.

How to Spot Medicare Fraud as an Employee of a Provider

Employees of healthcare providers who receive payments from Medicare are some of the most important whistleblowers. They frequently have a greater understanding of the law and greater access to the evidence that can be used to prove violations. Employees are also at a greater risk of being implicated if they participate in fraud or fail to report it.

If you are an employee, you should watch for the following signs of fraud. Your employer may be committing fraud if you…

  • Are instructed to change dates to misrepresent when services were performed
  • Are instructed to create records for services that were not performed
  • Are instructed to misrepresent who provided the services
  • Are instructed to submit duplicate bills to patients and Medicare
  • Are instructed to alter records before they are submitted to Medicare
  • Are offered incentives or rewards for directing patients toward certain products

All of these practices may be evidence of fraud. Make sure you preserve any instructions that you are given if you intend to report the fraud. Be aware that you are putting yourself at legal risk if you assist your employer in making false reports.

Information You Need to Collect to Report Fraud

Whistleblower lawsuits are complex. If you want the best chance for success, you need to make sure that you gather sufficient evidence before you report the fraud, or consult a lawyer about initiating a qui tam action. If possible, make sure you preserve all of the following information.

  • Identifying names and numbers for the provider’s involved
  • Identifying information for the service or item the fraud involves
  • The dates when the services were provided
  • How much Medicare paid for it
  • Why you think Medicare should not have been billed

Each case of fraud is unique, so you may be aware of other information that could provide more proof or further clarify how the fraud occurred. Document as much evidence as possible and keep it until you can speak to a lawyer.

Where to Report Medicare Fraud

You can schedule a consultation with a whistleblower lawyer to find out how you should proceed, or you can report it directly to authorities.

You can report fraud to Medicare at: 1-800-MEDICARE (1-800-633-4227)

Or, you can contact the Office of the Inspector General at: 1‑800‑HHS‑TIPS (1‑800‑447‑8477)

However, it is important to note, attorney representation is required in order to be eligible to receive financial whistleblower awards from recovered money.

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