Medicare, Medicaid, Medical Billing Fraud Whistleblowers

A Medicare fraud whistleblower is an individual who reports instances of fraud, waste, or abuse within the Medicare system, much as a Medicaid fraud whistleblower reports instances of fraud, waste, or abuse within the Medicaid program.

Both Medicare and Medicaid whistleblowers play a crucial role in identifying and stopping fraudulent activities within their respective programs. Whistleblowers may be employees, contractors, patients, or any others who have knowledge of fraudulent activities taking place within healthcare organizations or other entities that participate in the Medicare and Medicaid programs. Whistleblowers need to have original source information about the fraud which is information that has not yet been disclosed to the public.

How are Medicare and Medicaid whistleblowers protected from retaliation for reporting Medicare fraud?

Whistleblowers who report Medicare and Medicaid fraud may be protected by various federal and state laws, depending on the circumstances of the case. For example, the False Claims Act (FCA) is one of the primary laws that protects Medicare whistleblowers from retaliation, by allowing them to file lawsuits on behalf of the government against those who have defrauded government programs, including Medicare and Medicaid. 

In fact, whistleblowers may be eligible for Medicare fraud whistleblower rewards under the FCA if they report instances of fraud that result in successful recoveries by the government. The FCA allows private individuals to file lawsuits on behalf of the government against those who have defrauded government programs. If the lawsuit is successful and results in the recovery of funds, the individual may be entitled to receive a portion of the recovered amount as a reward.

The FCA also provides protections against retaliation for whistleblowers—they are protected from being fired, demoted, or otherwise retaliated against by their employers.

What are whistleblowers in medical billing?

Whistleblowers in medical billing are individuals who report fraudulent or improper billing practices within healthcare organizations or medical facilities. This includes billing for services not rendered or “phantom billing” which is when the medical provider charges Medicare or Medicaid for services, procedures, or supplies not provided. Another instance of fraud is “upcoding” or charging for more expensive services, procedures, or supplies than were actually needed. Whistleblowers who report medical billing fraud play an important role in identifying and stopping these costly, illegal activities. Whistleblowers can report fraud through various channels, including internal reporting mechanisms within their organization, government hotlines, or by filing lawsuits under the FCA if the fraud involves government healthcare programs like Medicare or Medicaid.