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How to Protect Yourself as a Medicare Whistleblower

Is it dangerous to be a Medicare whistleblower?

medicare whistleblowerThe benefits of being a Medicare whistleblower are tempting, but do they outweigh the risks? Most people want to do the right thing, but when they are under pressure to provide information, office staff, healthcare providers, doctors and others caught up in fraudulent schemes sometimes say they were afraid to speak out. For others, the lure of securing a major payout is their major motivation. Find out how to make a complaint to enjoy the most protection.

Medicare Fraud Does Not Happen by Accident

The Association of American Physicians and Surgeons recently did a survey of their members on the topic of Medicare fraud. What they found was shocking. Over 80 percent of doctors fear an investigation. The majority weren’t defrauding anyone. They’ve just bought into the idea that complicated billing codes are the root of recent fraud cases — and the sizeable financial ramifications.

Nearly a quarter of practices no longer accept Medicare patients for the same reason. They don’t want to deal with the risks. A look at actual cases involved Medicare fraud show these fears are unnecessary. Medicare fraud doesn’t happen by accident.

Take, for instance, the case of Williston Rescue Squad, Inc., in South Carolina. The ambulance service had a year’s long history of transporting patients by ambulance when it wasn’t necessary and falsifying documents to meet Medicare transfer requirements. Finally, a clinical social worker who worked at a local hospital turned in the business.

Remember, Medicare rarely pays all your medical bills. So as the government was being defrauded, so were the patients!  The company replaced three top executives and agreed to pay the government $800,000. Because the social worker raised the complaint by suing the company in a qui tam lawsuit, she received $160,000 of the settlement. The False Claims Act has revolutionized many industries by motivating change from within organizations. The protections involved are as important as the potential benefits, but they aren’t always what they appear.

Surprisingly, the lawsuit listed the name of the whistleblower and her association with the Williston Rescue. The company, her employer and the general public knew she spoke out. Her name is Sandra McKee. She still lives in Augusta, Georgia, and still works for U.S. Renal Care, Inc.

Protection for Whistleblowers Depend on How You Complain

Whistleblowing does not always guarantee your anonymity, though working with an experienced legal team can help safeguard your privacy. There are many ways to legally protect yourself from the backlash. For instance, federal law prevents:

  • Firing
  • Demoting
  • Harassment
  • Industry blacklisting
  • Unreasonable transfers

A common, new trend is employees getting into trouble for venting their concerns over social media. While these individuals believe they are doing the right thing, this doesn’t constitute “whistleblowing.” By airing grievances in the public eye, you open yourself up to ramifications at work, as well as potential legal problems. Your employer could fire you and sue for defamation. Courts are finding in favor of businesses in these situations. Employees fired for public complaints have also gone without unemployment.

That said, most employers cannot fire you for complaining directly to management. One whistleblower who remained anonymous not only successfully sued her employer for firing her in retaliation for complaints, she went on to sue the government for accepting too small of a settlement. And she won.

False Claims Cases Are Not Get-Rich-Quick Schemes

Consider the case of James Swoben, a former employee of a Medicare Advantage Organization doing business with DaVita Medical Holdings LLC. Swoben alleged the Medical Services Organization instructed their healthcare providers to use the wrong coding information to receive higher rates of reimbursement.

DaVita settled in October for $270 million, of which, Swoben received just over $10 million. However, he first filed the case and saw it dismissed in 2013. An appeal in 2016 revived the case. In addition, one of the original defendants – SCAN Health – settled early on by paying $322 million. Swoben didn’t receive any portion of that payment and had to fight for his right to compensation.

There have been so many qui tam lawsuits raised in the last three years, some courts are raising the stakes for what constitutes fraud. Others are limiting the scope of “retaliation.” One former employee found this out the hard way when she sued based on anti-retaliation protection after she resigned.

Handled differently, the employee could have been a source for positive change while benefiting financially. Finding the right lawyer to walk you through the process makes all the difference.

Click to find out more about Medicare whistleblower protection by contacting Bothwell Law Group online.

What Is the Process for Reporting Medicare Fraud?

Reporting Medicare Fraud

Reporting Medicare FraudIndividuals reporting Medicare fraud is one of the government’s only lines of defense. The system is so vast; it’s impossible to police every transaction. And as a result, they enacted the False Claims Act, designed to incentivize individuals aware of potential fraud to come forward. The law has morphed slightly over time, becoming more stringent, and with a particular focus on medical billing and practices.

One of the most common types of medical billing fraud is something called up-coding: billing the government for a process, procedure or medicine which costs more than what was administered. Let’s use up-coding as an example to explain how fraud happens, and process for reporting it.

How Up-Coding Happens Without Being Caught

The coding system itself is electronic, with a set of universal codes for every medical charge. Doctors and hospitals submit bills through insurance and the coding system, then on to Medicare. Because of the high number of transactions, Medicare audits less than 2% of the total volume. It’s a system practically begging to be abused!

Now do you see why the government must rely on individual citizens to help identify and report Medicare fraud?

What to Do When You Suspect Medical Claim Fraud

The first thing you need to do is gather proof and information. Any form of emails, letters, voicemails, alternate records, patient files and so forth are critical for reporting fraud. Once you have the information, you can best decide how to proceed next.

When to File a Qui Tam Lawsuit

If the fraud you discover is minimal, your best bet is to go through or the Office of the Inspector General. Likewise, if you suspect the fraud to be significant in size, but can locate very little proof, these may be your best bets.

However, if the scale and size are significant, and your evidence is substantial, you may want to consider filing a qui tam lawsuit under the False Claims Act.

Why You Might File a Qui Tam Lawsuit

In addition to feeling like a good citizen, reporting fraud to your government and helping to recover taxpayer dollars, you also become eligible for a portion of the recovery amount. As much as 30% of the amount covered can be awarded to you as a result of bringing the case to the government’s attention. In large-scale fraud cases, the size of the pie can be larger than most lotteries.

Consult a Legal Professional about Fraud

Your first step the moment you discover a shred of evidence should be to talk to a lawyer specializing in filing suit under the False Claims Act. They can help guide you toward the best solution based on the particulars of your case.

What Not to Do If You Suspect Medical Claim Fraud

Don’t start telling everyone you know you suspect fraud may be occurring. This violates some specific requirements for filing a qui tam suit, specifically that the perpetrator not be made aware of it. The technical term is filing “under seal” and you nullify the opportunity by making your suspicions public… even if the “public” in question is only immediate friends and family.

Ready to Find Out More about Reporting Medicare Fraud?

Still have questions about reporting Medicare fraud? Contact our team at Bothwell Law Group, and we’ll help you get the answers you need to make your decision.

How Does Legal Representation Work in a Medicare Whistleblower Case?

Medicare Whistleblower Case

Medicare Whistleblower CaseIf you’re thinking of filing a Medicare whistleblower case, you’re not alone. Every year, billions of dollars (yes, that’s billions with a B) are spent on false medical claims. Whether the source is inadequate care, illegal kickbacks, or overcharging for goods and services, the scope of fraud is frankly astronomical. In fact, one government audit estimated as much as 10% of Medicare charges are fraudulent!Medicare Whistleblower Case

Common Types of Medicare Fraud

In case you are wondering what qualifies as “fraudulent,” here is a list of some of the most common forms you might come across in any medical practice:

  • Double Billing: Billing for the same service more than once.
  • Fake/Phantom Charges: Charging for services that were never performed.
  • Up Charging: Billing for expensive equipment and testing when inferior items were actually used.
  • Co-payment Comps: Rolling required co-pays into the bill under false charging categories.
  • Kickbacks: Receiving a benefit from a company or lab in exchange for using them exclusively, or more than others.

And the list goes on and on. Every year, people find new ways to attempt to defraud the Medicare program. The government must rely on good citizens to turn in the fraudsters, blowing the whistle on illegal activities. This is the heart of the False Claims Act.

Filing a Whistleblower Suit…Or Not

Once you become aware of any fraudulent activity against the government, the first thing you should do is stay quiet and hire a lawyer. Be sure to do some research, and interview a few firms. This is incredibly important as your lawyer will be a vital part of your success, and determining the size of reward you may be eligible to receive.

Once your attorney has reviewed the case, they can advise you on the best course of action. In some instances, it may be in your best interest NOT to file suit. Your lawyer should explain the possible outcomes, ramifications, and the likelihood of success so you can make an educated decision.

If you do decide to proceed, you will be filing as a private citizen acting in the interest of the government, to recover funds on their behalf. You may or may not need to cover attorney fees accumulated up to this point; be sure and ask about the billing and settlement process during the interview phase.

Government Review of Medicare Fraud Suits

Your lawsuit will be filed in secret (AKA “under seal”), and only you, your attorney, and the government will be aware it exists. The government has this opportunity to review all the facts, findings, and proof contained in your supporting documents. Based on the strength of the case, the government then chooses whether or not to join your case, or intervene.

Government Intervention for Whistleblower Lawsuits

If the government joins, they take over pursuit of the case, working with your lawyer to hand it off to their attorneys. This is a good thing, as cases where the government intervenes have a much higher success rate. Your payout is then determined at the end of the trial, and most of your attorney fees are likely covered through the payout.

If the government doesn’t intervene, then you have to choose whether to push forward or not. Your share of the payout will be higher if you succeed, but if the lawsuit fails, you may be liable for all your attorney fees.

Looking for More Information on Whistleblower Legal Representation?

Contact the skilled Medicare whistleblower case attorneys at Bothwell Law Group by calling 770.643.1606 today.