Medicare Fraud under the False Claims Act

The Federal Government spends $500+ billion a year to provide health insurance to the elderly in the United States through its Medicare program.  Estimates are that at least $60 billion from that spending happens because of improper payments.  The amount of Medicare fraud that is recovered annually is much lower – generally between $1 and $3 billion during President Obama’s administration.

If you have evidence of Medicare fraud, our whistleblower attorneys can assist you with reporting it to the Justice Department and the investigators for the Department of Health and Human Services.  Call McEldrew Young at 1-800-590-4116 for a free, confidential initial legal consultation.

The primary tool to recover government spending lost to health care fraud is the False Claims Act.  The False Claims Act was passed by Congress during the 1860s and has been expanded over the years.  Now, it is the nation’s leading tool in the fight against fraud against the government.

The False Claims Act provides for whistleblowers to report health care fraud against Medicare by drug companies, medical device manufacturers, hospitals, doctors and other health care professionals.

How are Medicare whistleblower rewards paid?  Once the qui tam lawsuit filed by the relator and his/her counsel has been resolved, the Government will pay a percentage (between 15 and 30 percent) of the collected proceeds to the whistleblower.

Types of Medicare Fraud

Billing Fraud: Health care services provided by in-patient hospitals are covered by Medicare Part A and other services (outpatient centers, skilled nursing facilities, home health care agencies, laboratories, etc.) are covered by Medicare Part B.  These providers bill Medicare directly when their patient presents it as their form of insurance.  If they knowingly submit a claim for payment for a service that they did not perform, the service performed was medically unnecessary, or they seek an amount in excess of what they are entitled to under the Medicare program, then they are engaged in Medicare fraud.

Medicare Advantage:  Many participants choose to enroll in insurance managed by an insurance provider rather than the federal government.  The government pays the insurance provider a set amount per patient based on risk scores.  If the company is improperly manipulating the risk score to increase the payout they receive, they are committing health care fraud.

Part D: This is the prescription drug plan offered by Medicare.  When drug companies offer or pay kickbacks to doctors in order to increase their prescriptions, it implicates Part D fraud.