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What is a Medicare Whistleblower?

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  • Written By: Daphne Mallory
  • Edited By: Melissa Wiley
  • Last Modified Date: 29 November 2016
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A Medicare whistleblower is a person who reports Medicare fraud. Medicare is a federal health care benefit available to seniors in the United States. Medicare fraud occurs when medical institutions and health care providers collect reimbursement for services and medical care by fraud, including double billing, false coding, and intentionally charging for services that patients did not receive. Patients and employers are often whistleblowers, and there are whistleblower laws to protect them and encourage the public to bring forward knowledge of businesses and others that are defrauding the federal government. A Medicare whistleblower lawyer represents a whistle blower in Medicare fraud cases, which are referred to as qui tam lawsuits.

Medicare is funded by the taxpayers, and fraud that is left unexposed often costs the taxpayers billions of dollars each year. Some medical providers defraud Medicare because they are guaranteed reimbursement and a cash flow. For example, hospices around the United States have been caught filing Medicare claims for patients who were not eligible to receive benefits as a means of obtaining cash to fund the hospices’ operations. These businesses often defraud Medicare because seniors may not be able to afford their services otherwise. Medicare whistleblowers working for these companies often become aware of the fraud and report it and join the government in whistleblower lawsuits.

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Under federal laws, an individual involved in fraud reporting is entitled to a whistleblower reward if the government is able to recover proceeds in a lawsuit or if the individual files a lawsuit. The False Claims Act outlines the rewards available and specifies that the whistleblower has to be the original source who leads to a successful lawsuit exposing the fraud. The government may or may not decide to proceed with legal action. If it does, the whistleblower is often able to receive between 10 and 25 percent of the proceeds awarded to the government. The Medicare whistleblower can bring a qui tam lawsuit on the government’s behalf and can often recover 25 to 30 percent of what the civil court determines is reasonable for damages. The percentages also pertain to any settlement reached prior to the conclusion of the trial.

The False Claims Act also provides protection to the whistleblowers against retaliatory acts by those who defraud Medicare. For example, employers will be liable to compensate the Medicare whistleblower if he or she is demoted, fired, or suspended as a result of reporting the fraud. The employer would have to pay twice as much as the back pay that the employee earned, as well as special damages.

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