Using the Federal False Claims Act to Report Medicare and Medicaid Fraud

Nathan Eisenberg

Billing and paperwork are an inescapable part of the healthcare profession.  However, where an individual or institution submits fraudulent paperwork to make claims for payment to the federal government – such as Medicare or Medicaid reimbursement claims, or makes claims for payment from a government program for services that were never provided, filing the “false claims” violates the law.  The Federal False Claims Act provides a mechanism for whistleblowers who report this kind of fraud to bring a lawsuit on behalf of the government with a private attorney. And if, as the result of the lawsuit, the government successfully recovers funds that were improperly paid, the whistleblower can recover a portion of those recovered funds.

Health care professionals sometimes observe billing problems that reflect that health care institutions are overbilling Medicare and Medicaid. This may include:

  • Billing for services or equipment that was not provided,
  • Billing for services or items that were improperly provided,
  • Unbundling medical services to allow for double billing for services,
  • Falsifying documentation to obtain reimbursement for services that would not otherwise be covered, or
  • “Upcoding” or “upcharging” by using improper codes to obtain reimbursement from Medicare/Medicaid at a higher rate.

The False Claims Act applies to allegations that a person or business is defrauding the government by obtaining payment or reimbursement from the Federal government to which that person or business is not actually entitled. Fraud against a private business is not covered.

The FCA also protects “whistleblowers” from retaliation for reporting the fraud and allows an individual with personal knowledge of the fraudulent conduct to bring a lawsuit on behalf of the government as the plaintiff, or “relator.” Generally, the relator should have personal knowledge of, and be the original source of the information about, the fraudulent activities. A FCA lawsuit may not be based on publicly available information about a fraud.

The FCA provides an incentive to encourage individuals to bring these lawsuits: if successful, the FCA plaintiff can receive 15% to 30% of the amount recovered as the result of a settlement or after a trial.   The monetary recovery in False Claims Act suits depends on both the number of violations and the amount of money that was received as the result of the fraud.  The recovery includes a penalty of $5,500 to $11,000 per false claim, plus an amount equal to three times the amount of the false claims.

If you have questions about reporting fraud under the False Claims Act, contact The Previant Law Firm for a free consultation today at (414) 240-1185.