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How Are Medicare Whistleblower Rewards Paid?

How Are Medicare Whistleblower Rewards Paid

How Are Medicare Whistleblower Rewards PaidAre you looking for answers regarding how Medicare whistleblower rewards are paid? The truth is Medicare whistleblowers can wind up with a very lucrative payout. By seeking qualified representation for whistleblower law and Qui Tam Law cases, a whistleblower’s potential for a payout from the liable parties can be substantial.

What Is the Whistleblower Law?

The whistleblower law is part of the False Claims Act, which was created in 1863 to crack down on Civil War profiteering. The False Claims Act was revamped and amended by Congress in 1989, making it more accessible and rewarding for any citizen to report false claims against the government. In essence, the law provides both reward and protection from retribution for someone who reports a validated fraud against the government or against public interest.

Whistleblowers, those who speak up about illegal practices affecting government agencies and other industries, have often been silenced by various forms of retribution including job loss, promotion freezes, blacklisting, and many other damaging practices.

The whistleblower law encourages citizens to come forward and inform the government of such fraudulent acts by protecting them from these consequences. The addition of the Qui Tam Law extends these rights by allowing the whistleblower to be rewarded financially, based on the amount recovered by the government in the court action.

How Does Qui Tam Work?

The Qui Tam Law allows an individual, known as a relator, to bring a lawsuit based on claims against the False Claims Act. The citizen, with a lawyer who is knowledgeable about the False Claims Act, brings the evidence to the court and asks the court to investigate the claim.

A relator is someone who has first-hand knowledge about the fraud. They will have access to documents to prove the claim. A Qui Tam claim is kept under seal, confidential, for at least 60 days, initially, although it is not uncommon for the court to extend this time. During the investigation, the entire matter is kept secret. The individual(s) being investigated are not made aware of the allegations or the inquiry.

Evidence in these cases can include things like shipping reports, invoices, bidding information, profit information among many other types of documents. The evidence must be first-hand, direct knowledge, supported by documents. If the court decides there is ample evidence to proceed, they will intervene, and they will then prosecute the case.

You remain a party to the case and cannot be dismissed or removed from the case without a hearing. If the government does not intervene, you can continue the case without them, through your whistleblower representation lawyer. It is much harder to win without the government intervention, but if you do, the reward is higher.

How Are Medicare Whistleblowers Paid?

The relator- whistleblower- is paid via a system determined by the False Claims Act. It begins with the court determining the amount of the penalties owed by the provider or practice. As a part of the lawsuit, the number of violations is added up. The letter of the law states that every single line of billing that is fraudulent is a separate violation, even if there are 25 on a single form. However, many courts have determined that each form is a violation, even if there are 25 separate entries. Once the number of violations is clear, the formula comes into play.

For each count, there is a penalty of between $5,500 and $11,000. Also, the amount of money the government was defrauded is refunded times three. When you consider that a winning case in court probably has hundreds or thousands of claims, the penalties can add up to tens of millions or even hundreds of millions of dollars in some cases.

The relator- the whistleblower- is awarded from 15-30% of the money recovered by the government. The potential for a very large reward is clear. It is not unusual for whistleblowers to receive rewards in the millions of dollars on large, high profile claims.

Some of the highest payouts ever made to whistleblowers include Medicare fraud. In 1999, Whistleblower George Courto, who worked for Bayer, filed a Qui Tam action against his employer and GlaxoSmithKline for selling relabeled drugs to an HMO on the cheap and not reporting the information to avoid paying millions of dollars in rebates to Medicaid. The total payout came to $344 million dollars and $34 million went to the estate of the whistleblower. In another Medicare case, GlaxoSmithKline paid out $333 million in penalties. The whistleblower here received over $53 million.

If you work for any provider that bills to Medicare and you are concerned about fraud issues, you should talk to an attorney who can help. The best way to know if an actual crime is being committed, and to keep yourself protected in the event of a blame-game, is to speak with an attorney who deals exclusively with whistleblower Qui Tam cases.  Have questions about how Medicare whistleblowers are paid? Click to contact the Bothwell Law Group online.

What Are Some Typical Types of Whistleblower Medicare Fraud that Goes to Court?

whistleblower medicare fraud

whistleblower medicare fraudIf you work for, or have knowledge of, any company violating any laws or regulations pertaining to Medicare and Medicaid, you could be a whistleblower for Medicare fraud. And if these violations fall under the scope of the False Claims Act, you may have grounds for a lucrative qui tam lawsuit; up to 30% of monies recovered if the court finds in your favor.

While the money is certainly a great incentive, active participation and oversight from people most closely involved in the healthcare industry prevents billions of lost taxpayer dollars. In 2014 alone, the Justice Department recouped $6 billion in FCA claims, with nearly half that amount stemming from healthcare fraud.

What Constitutes Healthcare, Medicare, or Medicaid Fraud?

Many businesses and industries receive funds from the federal government both directly and indirectly. This includes hospitals, nursing homes, private physicians, pharmacies, laboratories, medical equipment providers, and many more. Any action that leads to receiving government money, or postponing payment to the government, for fraudulent reasons, is fair game. To make it easy for you, we’ve created a list of some of the most common occurrences:

  • Charging for a full prescription, but only partially filling it
  • Kickbacks to physicians and other medical providers in exchange for exclusively using certain products, or prescribing specific medications
  • Ordering tests that are not medically necessary
  • Prescribing drugs or treatment not medically necessary
  • Increasing billing prices solely for Medicare or Medicaid patients
  • Knowingly providing substandard or defective medical devices
  • Knowingly providing substandard medical services
  • Falsely diagnosing a more significant medical issue than the one a patient actually has in order to charge for more intense and expensive treatments (commonly called upcoding)
  • Changing a prescription to a more expensive treatment as a result of kickbacks
  • Falsifying drug research grant information and outcomes
  • Charging for treatments, prescriptions or services separately when they can be performed together at a reduced cost (sometimes called unbundling)
  • Steering individuals to a specific course of treatment, medicine, or medical company when you have a vested interest in company performance (commonly called self-referrals)
  • Double billing both the government and private insurance or the patient
  • Falsifying records to meet compliance standards (most common with medical devices and machines)
  • Submitting bills to Medicare that don’t apply under the Secondary Payer
  • Requesting reimbursement for costs related to non-Medicare patients
  • And more…

You can see from the list above the many ways different individuals and businesses can go about defrauding the government. It’s almost impossible to catch it all, which is why the government relies on whistleblowers. Ensuring there is a proper system in place for both the reporting of fraud, and protection of the individual making the claim is the reason the False Claims Act and qui tam provision exist today.

Filing a Qui Tam Lawsuit

If you think you may have knowledge of Medicare, Medicaid, or other healthcare fraud, you should contact a lawyer immediately. They’ll be able to tell you what the options are, and keep you from doing anything that may compromise the grounds for your case. Plus, they can help you gather the information you need to adequately support your lawsuit inside both the Justice Department and the courtroom.

Still have questions about being a whistleblower for Medicare fraud? Call 770.643.1606 to contact the Bothwell Law Group online.

Top 5 Reasons the Medicare Whistleblower Hotline Is Called

Medicare Whistleblower Hotline

Medicare Whistleblower HotlineIn an attempt to simplify and encourage more citizens to blow the whistle on Medicare fraud, Medicare whistleblower hotlines have been set up throughout the country. The purpose of a Medicare whistleblower hotline is to provide an easy and anonymous way for employees to report evidence of suspected illegal activity within their workplace.

There are various reasons why an employee may call a Medicare whistleblower hotline, but there are some reasons that are more common than others. Continue reading for the top 5 reasons the Medicare whistleblower hotline is called:

#1. Billing for a service that was not provided.

A healthcare provider may be routinely billing for procedures, most commonly diagnostic tests, that they have not provided to a patient. When the patient receives the incorrect statement, they typically call their provider first instead of Medicare that allows for this type of fraud to go unnoticed.

#2. Billing for supplies that were not provided.

Similarly to the scenario above, some providers may routinely bill Medicare for a supply under the false pretense that they have supplied it to a patient.

#3. Up-coding to be reimbursed at a higher rate.

Some healthcare providers may make a habit of up-coding, or billing a service as a higher paid procedure or test that was not performed. As an employee, reporting this type of fraud is incredibly important since an estimated 2% of Medicare claims are audited for up-coding.

#4. Misrepresenting a diagnosis or procedure.

If a procedure is not covered under Medicare, some healthcare providers will code it inaccurately to obtain reimbursement for that service. Additionally, since Medicare can only cover services that have been deemed as absolutely medically necessary, some healthcare providers will misrepresent a diagnosis as a way to obtain reimbursement for a service that would not be covered under normal circumstances.

#5. Billing bundled services individually.

There are multiple services, especially surgical or diagnostic services, that are bundled together to be billed as one service. In some cases, providers are unbundling these services and billing them separately across several bills as a way to receive additional compensation for a service provided.

The desire to submit an anonymous tip concerning Medicare fraud is completely understandable as many employees fear retaliation at the hands of their employer. However, there are laws in place that protect whistleblowers from retaliation. Although an anonymous call to a Medicare whistleblower hotline is helpful, lawsuits presented with evidence of fraud are more highly prioritized by the government and anonymous whistleblowers cannot be rewarded if the defendant is found liable.

Bothwell Law can assist you in filing a Medicare False Claims lawsuit and teach you what you need to know to protect yourself from retaliation. Find out what you need to know about the Medicare whistleblower hotline by clicking this link or calling 770.643.1606.