How to Report Medicare Fraud

Fraud is a serious problem that robs Medicare of hundreds of millions of dollars every year. Reducing this fraud is no simple matter. Medicare is the largest health program in the United States, and it generates more transactions annually than can be reasonably investigated for fraud.

In order to detect and prosecute this fraud, the US is highly dependent upon whistleblowers who are willing to report Medicare fraud and provide the evidence necessary to bring cases forward. To encourage whistleblowing, the US relies on a law known as the False Claims Act (FCA).

Medicare Fraud

Medicare fraud is a broad term that covers any action that results in the defrauding of the Medicare public health insurance program. As one of the largest insurance programs in the US, it makes billions of dollars in disbursements every year to providers that include doctors, hospitals, pharmacies, hospices, and drug manufacturers.

The amount of money and transactions involved can make fraud tempting and difficult to detect. However, the government has many tools for detecting and reclaiming money lost to fraud—even years after the fraud was committed.

One of the ways the fraud is detected is through the use of the False Claims Act and the incentives that law offers to whistleblowers who are directly employed by the providers who receive Medicare funds.

The False Claims Act

The False Claims Act (FCA) is the federal law that criminalizes the submission of false claims by organizations that accept cash or services from federal programs. It covers most types of false claims, including falsified records, inflated invoices and the misrepresentation of eligibility information. It is one of the US government’s most effective tools against large-scale fraud.

One feature of the Act that makes it particularly effective is the qui tam provision that incentives and rewards whistleblowers.

Qui Tam Lawsuits: What a Whistleblower Needs to Know

A qui tam lawsuit is a type of lawsuit that is brought by a whistleblower on behalf of the government. In cases where the government has been defrauded of funds, a qui tam provision allows anyone with knowledge or evidence of the fraud to file. In return for their service, the law allocates them a share of the funds that are recovered.

Qui tam provisions are relatively rare in US laws. The most prominent and most frequently used qui tam provision is the one that is found in the False Claims Act.

The False Claims Act is a piece of legislation that dates back more than 100 years. It criminalizes the submission of false reports, records, and claims to certain federal programs, and includes a qui tam provision so that whistleblowers may act to seek the recovery of stolen funds when the criminal fraud is committed.  

The False Claims Act is frequently used in cases where the defendant is accused of fraud against Medicare, Medicaid and other public programs that are directly funded by the US government.