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Medicare Fraud Whistleblower: What Are the Rules?

Medicare Fraud Whistleblower

Medicare Fraud WhistleblowerIf you know of Medicare Fraud, you may have occasion to be a Medicare Fraud Whistleblower. It’s important to know what the rules are.

One such whistleblower, Jacqueline Bloink, initiated a legal action resulting in a $35 million settlement to the federal government. Bloink is a former employee of the Carondelet Health Network and provided evidence of them submitting false claims to Medicare.

As a result, Medicare Fraud Whistleblower, Jacqueline Bloink, earned nearly $6 million.

What is considered Medicare Fraud?

  • Knowingly submitting false statements or misrepresenting facts to get federal health care payment when an entitlement would not exist otherwise;
  • Knowingly paying, soliciting, and/or accepting remuneration to reward or induce referrals for services or items reimbursed by Federal health care programs;
  • Making prohibited referrals for certain designated health services.

Obviously, defrauding the Federal government is illegal. Criminal and civil remedies for committing Medicare fraud include:

  • Fines
  • Imprisonment
  • Penalties
  • Exclusion from participation in Federal health care programs
  • Loss of professional licenses

5 Laws Governing Medicare Fraud:

  • United States Criminal Code
  • Anti-Kickback Statue (AKS)
  • False Claims Act (FCA)
  • Physician Self-Referral Law (Stark Law)
  • Social Security Act

5 Conditions That Must Be Met according to

  1. You report your suspected Medicare fraud. The allegation must be specific, not general.
  2. The suspected Medicare fraud you report must be confirmed as potential fraud by the Program Safeguard Contractor, the Zone Program Integrity Contractor, or the Medicare Drug Integrity Contractor (the Medicare contractors responsible for investigating potential fraud and abuse) and formally referred as part of a case by one of the contractors to the Office of Inspector General for further investigation.
  3. You aren’t an “excluded individual.”


For example, you didn’t participate in the fraud offense being reported. Or, there isn’t another reward that you qualify for under another government program.

  1. The person or organization you’re reporting isn’t already under investigation by law enforcement.
  2. Your report leads directly to the recovery of at least $100 of Medicare money.

For more information about the Medicare Fraud Whistleblower Rules, have a confidential consultation with an experienced Whistleblower Attorney. They can help you navigate the tricky waters of a whistleblower law suit and help protect your rights. It’s important to know the rules, know your rights, know the laws surrounding Medicare and whistleblowing, and know the process inside and out.