How to Earn Financial Rewards for Reporting Medicaid Fraud

​To earn a financial reward for reporting Medicaid fraud, you must have evidence that false or fraudulent claims have been submitted to the Medicaid program.  

It is not enough to have suspicions.  You need to be able to give the government evidence in the form of billing records, patient charts, or communications such as emails, text messages or memos.  The information you provide must not already be under investigation by authorities, and the fraud must be significant and widespread to be eligible for a reward.

If the government recovers money as a result of your information, you will be entitled to a financial reward equal to between 15% and 30% of the total amount recovered by the government.  The exact percentage depends on various factors, including the significance of the information provided and whether the government intervenes in the case.

By helping the government uncover and stop Medicaid fraud, you will also earn the right to very important whistleblower protections.  The False Claims Act protects whistleblowers from retaliation by their employers.  This includes legal remedies such as reinstatement, back pay, and compensation if the whistleblower faces adverse actions as a result of their whistleblowing.

​Identifying Medicaid Fraud

The most common types of Medicaid fraud are perpetrated by hospitals, nursing homes, clinics, urgent care centers, pharmaceutical companies, and individual healthcare providers.  Some of the most common frauds are:

Phantom Billing:  This involves billing Medicaid for services or goods that were never provided.  It is a common scheme where providers submit claims for treatments or procedures that did not occur.

Upcoding:  This occurs when providers bill for a more expensive service than what was actually provided.  It involves inflating the complexity or intensity of the services rendered to receive higher reimbursements.

Unbundling:  Providers engage in unbundling when they bill for multiple services separately that should be billed as a single package.  This practice increases the total reimbursement amount fraudulently.

Billing for Medically Unnecessary Services:  Providers may perform and bill for tests or procedures that are not medically necessary, often to increase revenue through unnecessary services.

Double Billing:  This involves billing Medicaid and another payer for the same service, or billing Medicaid multiple times for the same service.

Kickbacks and Self-Referrals:  It is illegal for a healthcare provider to pay or receive compensation for referring patients to specific providers or facilities.  It is a form of bribery that distorts patient care decisions.  It is also illegal for healthcare providers to refer patients to certain types of facilities that they own or control, or that are owned or controlled by their family member.

These fraudulent activities not only waste valuable public funds but also compromise the integrity of the healthcare system and can lead to severe legal penalties for those involved.

​Qualifying for a Whistleblower Reward

Once you have the evidence, the next step is very important.  Do not simply turn the evidence over to the government.  They will say “thank you” and give you nothing.  To qualify for a financial reward, you must follow very specific procedures under the False Claims Act.  

You must retain a lawyer to help you prepare and file the necessary documents.  Do not worry about the lawyer’s fees.  If you have the evidence, an experienced whistleblower lawyer will represent you on a contingency fee basis.  This means that you will not owe your lawyer any fees unless you win a financial reward.

Your whistleblower lawyer will review all of your evidence and identify the types of claims you may bring under the False Claims Act.  He will also help you prepare two very important documents.  

The first document is a “disclosure statement” that describes all of your evidence.  This is the heart of your whistleblower claim.  It will lay out, in detail, the nature of your Medicaid fraud claims, the evidence supporting each of the claims, and the reasons why the government should conduct a thorough a thorough investigation.  The disclosure statement will also provide the government with a road map for conducting an investigation by explaining who has knowledge of the fraud, where the important documents are located, what types of information is available on computer files, and other sources of evidence.  Once you and your lawyer agree on the final version of your disclosure statement, it will be provided to the government in secret to aid in an investigation of your claims.

The second document is a “qui tam complaint” that will be filed “under seal” in court.  Filing the complaint “under seal” means that it will not be available in the public record.  In most courts, the complaint will be kept in a sealed envelope in a safe in the clerk’s office until the government completes its investigation.

During the investigation, your lawyer will represent you in discussions with the government about your claims.

How Much Can Whistleblowers Earn as a Reward?

Whistleblowers who report Medicaid fraud earn significant financial rewards under the False Claims Act.  They typically receive between 15% and 30% of the total amount the government recovers as a result of the fraud case.

Some of the largest whistleblower rewards for reporting healthcare fraud have involved off-label marketing of drugs by large pharmaceutical companies.  For example, several whistleblowers shared very large rewards when Glaxo-Smith-Kline $3 billion to settle allegations of fraud related to the marketing of drugs. Other whistleblowers shared more than $12 million in rewards when Schering-Plough Corporation and a related company paid $435 million to resolve accusations of improperly marketing drugs for unapproved uses and lying about drug prices.

Whistleblower claims against nursing homes and hospitals have also resulted in very significant rewards for the individuals who gave the government evidence to stop the fraud.  For example, an individual whistleblower received a multi-million dollar reward when a NYC hospital agreed to pay $12 million to settle claims that it submitted false cost reports to obtain higher reimbursement rates from Medicare.  Another whistleblower also received a multi-million dollar reward when one of the nation’s largest nursing home chains and a related company paid $104.5 million to resolve claims that Vencor knowingly submitted false claims to Medicare, Medicaid, and TRICARE, the military’s healthcare program.

The size of a whistleblower reward is determined by several key factors.  Some of the main factors are:

Significance of the Evidence:  The importance and relevance of the evidence provided by the whistleblower to the successful enforcement of the case are crucial.  The more significant the contribution, the higher the potential reward.

Timeliness:  The promptness with which the whistleblower reports the fraud can impact the reward.  Early reporting can lead to quicker investigations and potentially larger recoveries, thereby increasing the reward.

Assistance Provided:  The extent of assistance provided by the whistleblower during the investigation and litigation process can affect the reward size.  Whistleblowers who actively help in building the case may receive higher rewards.

Quality of Information:  The accuracy, reliability, and completeness of the information provided are critical.  High-quality information that directly leads to successful legal action can result in a larger reward.

Complicity:  If the whistleblower was involved in the wrongdoing, this could reduce the reward.  The level of the whistleblower's involvement in the fraud is considered when determining the reward percentage.

Impact on the Public Interest:  The potential impact of the whistleblower’s information on protecting the public interest or preventing future fraud can also be a factor in determining the reward.  When it comes to healthcare fraud, protecting patients from harm is a primary concern.

​Do You Qualify for a Whistleblower Reward?

There is only one way to find out whether you qualify as a whistleblower and, if so, how much your case might be worth.  You need to consult with an experienced whistleblower attorney.  Do not delay.  In most cases, only the first whistleblower is entitled to a reward.

John Howley, Esq. is a whistleblower attorney with unique experience.  For 20 years, he represented some of the largest healthcare companies in the world, including hospitals and major pharmaceutical companies such as Pfizer, Novartis, and GlaxoSmithKline.  He formed The Howley Law Firm to provide individual whistleblowers with the same high-quality, aggressive representation that large companies have.

To schedule a consultation, call The Howley Law Firm at (212) 601-2728.  The initial consultation is free and completely confidential.