What Counts as Medicare or Medicaid Fraud?

• Billing for services not rendered, including visits that did not happen, tests never run and supplies never delivered.
• Upcoding, billing a higher level of service than was performed, and unbundling, billing separately for services that must be billed together.
• Medically unnecessary services, including tests, procedures, admissions and durable medical equipment ordered to generate revenue rather than to treat the patient.
• Kickbacks: payments, free services, sham medical director fees, speaker fees or anything else of value given to induce referrals. A claim that results from a kickback is a false claim even if the service was provided and was needed.
• Self-referral: a physician referring Medicare patients to a facility in which the physician has a financial interest, outside the narrow exceptions.
• Hospice and home health fraud: enrolling patients who are not terminally ill or not homebound, and billing for care not given.
• Nursing home fraud: billing for therapy not provided and worthless services, where the care is so poor it has no value.
• Medicare Advantage risk adjustment fraud: reporting diagnoses patients do not have, or that were not documented, to raise the plan’s monthly payment.
• Laboratory and genetic testing fraud, including tests ordered through telemarketing and paid-for orders.
• Pharmacy fraud: billing for prescriptions never picked up, automatic refills no one asked for, and switching drugs to raise reimbursement.

How a False Claims Act Case Works

The False Claims Act lets a private person, called a relator, file a lawsuit in the government’s name against anyone who knowingly submits a false claim for federal money or knowingly avoids an obligation to pay the government. The complaint is filed under seal in federal court and served on the Department of Justice, not on the defendant. The government investigates while the seal is in place, which usually takes a year or more, and then decides whether to take over the case. If the government joins, the relator generally receives 15 to 25 percent of what is recovered. If the government declines and the relator goes forward alone, the share is 25 to 30 percent. A defendant that loses pays three times the government’s damages plus a civil penalty for each false claim, which the government adjusts for inflation each year and which now runs from more than $14,000 to more than $28,000 per claim. The person who files first with the information controls the case; a later relator with the same facts is barred.

Who Brings These Cases?

Billing and coding staff, compliance officers, nurses and therapists, physicians and physician assistants, pharmacists and pharmacy technicians, practice administrators, sales and marketing employees of labs and device companies, and former owners and executives. You do not have to be a current employee. You do have to have information the government does not already have, in enough detail to show that false claims were actually submitted.

What Our Firm Does

• Review what you know and decide whether it supports a case under the federal act, a state act, or both.
• Prepare the complaint and the written disclosure to the Department of Justice, which is what persuades the government to investigate.
• File the case under seal and handle the government’s investigators and attorneys on your behalf.
• Litigate the case if the government declines to join.
• Protect you from retaliation and pursue your relator’s share.

Before You Report

• Do not confront the people involved or announce what you intend to do.
• Do not use a work computer, work phone or work email to contact a lawyer.
• Do not take documents you do not already have a right to see. Ask us first what you may keep.
• Write down what you know: who, what, when and how you know it.
• Do not wait. The first person to report is in the strongest position, and a later report with the same information may receive nothing.

Frequently Asked Questions

Can I report Medicaid fraud if the money came from the state?

Yes. Medicaid is paid with federal and state money, so a false Medicaid claim violates the federal False Claims Act, and New Jersey, New York, Maryland and the District of Columbia each have their own false claims act covering the state share. Pennsylvania has no general false claims act, so a Pennsylvania Medicaid case proceeds under the federal act.

Do I need documents to bring a case?

You need enough detail for the government to believe false claims were submitted: who, what, when, how you know, and ideally examples of claims. Do not take patient records or anything you are not already allowed to have. Tell us what you have seen and we will tell you what you may keep.

Will my employer find out?

Not while the case is under seal. Your identity generally becomes known if the government joins the case or the case is unsealed and goes forward. Retaliation for filing or helping with a False Claims Act case is unlawful, with reinstatement, double back pay and attorney fees available.

How long do I have?

A False Claims Act case must be filed within six years of the violation, or within three years of when the government knew or should have known of it, but never more than ten years after the violation. Waiting also risks someone else filing first.

What does it cost?

The first conversation is free and confidential. If we take your matter, the fee terms are put in writing before any work begins.

Talk to Us Before You Report

Email msiddons@siddonslaw.com from a personal account with a general description of what you know. Do not send documents. We will reply and tell you what to do next. Attorney Michael A. Siddons represents whistleblowers in Pennsylvania, New Jersey, New York, Maryland and Washington, D.C.