What is Healthcare Fraud?

Government-funded healthcare programs don’t just provide essential healthcare services to people who need them—they’re also big business. In 2021, the federal government spent $901 billion on Medicare and $734 billion on Medicaid. Even though the vast majority of these funds are used for their intended purposes, there’s always the temptation for unscrupulous business owners to take more than their fair share when that much money is on the table. Fraudulent claims for Medicare and Medicaid reimbursement are governed by the federal False Claims Act, which protects whistleblowers from retaliation and gives them the option of bringing their own lawsuits against offenders. If you suspect that your employer might be defrauding Medicare or Medicaid, what are your options?

Option 1: Raise the Issue Internally

It’s possible that what looks like Medicare or Medicaid fraud might be a misunderstanding. Maybe your employer misunderstands the requirements for reimbursement. Or maybe you aren’t exactly clear about what your employer is doing. If the situation is a genuine misunderstanding, then a simple conversation might clear the air.

Of course, raising your concerns about fraud with your employer carries risks. If you make an internal complaint, it’s important to know that the False Claims Act makes it illegal for your employer to fire you in retaliation for the complaint or retaliate against you in any other ways—even if it turns out that the employer wasn’t actually breaking the law. What matters is whether your complaint was based on a good-faith, reasonable belief that your employer may have been committing fraud. If you have been fired in retaliation for making such an internal complaint, you have the right to bring a lawsuit for damages, including reinstatement to your position, twice the amount of your lost wages, damages for emotional distress, and the costs and expenses of litigation, including attorney fees.

Option 2: Contact the Government

If you don’t want to raise your concerns internally, you can also report your concerns directly to the federal government by contacting the Office of the Inspector General in the Department of Health & Human Services. This will allow the government to investigate your concerns and act to stop any fraud that it discovers.

Reports to the government are also protected under the False Claims Act in the same way as internal complaints. So long as your report was based on a good-faith, reasonable belief that your employer may have been defrauding the government, your employer cannot retaliate against you.

Option 3: File a Lawsuit Yourself

If you are reasonably certain that your employer (or former employer) is defrauding Medicare or Medicaid, you can skip the complaint process and file a lawsuit directly against the employer yourself. Such lawsuits are brought by private individuals on behalf of the federal government. They are often called “qui tam” lawsuits (usually pronounced “key tam” or “key tom”), a shortened version of a longer Latin phrase regarding when an individual sues on their own behalf as well as the state’s behalf.

Through a qui tam lawsuit. you can use the power of the courts to stop your employer from defrauding Medicare or Medicaid. But more than that, if your lawsuit succeeds, you have the right to receive a percentage of all funds that the government recovers from your employer—usually between 15 and 30 percent. In 2021, qui tam whistleblower suits under the False Claims Act led to more than $1.6 billion in judgments and settlements, most of which concerned healthcare fraud. That’s a big incentive for a whistleblower to come forward with their own lawsuit—but keep in mind that if you also reported your suspicions to the government and the government begins its own action, you aren’t entitled to a share of the recovery.

Hawks Quindel Attorneys Are Here to Help

Working in the healthcare industry is stressful enough without worrying whether your employer is defrauding the government. Fortunately, you’re not alone. Our firm has considerable experience in enforcing employees’ rights against retaliation and bringing employer misconduct to light. If you think your employer might be committing healthcare fraud, or if you think your employer has retaliated against you because of your internal or external complaints, contact Hawks Quindel, S.C. to schedule a consultation with one of our experienced employment attorneys.

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