Who’s fighting healthcare fraud on the inside?
Billions of dollars get siphoned away from Medicare, Medicaid, and private insurance programs every year. And the truth is… If it weren’t for whistleblowers coming forward from the inside… Most of it never gets detected.
Whistleblowers partner with healthcare whistleblower attorneys to expose fraud. These lawyers help bring cases to light.
The result? Recoveries in the billions for taxpayers. Increased scrutiny and penalties for fraudsters. Better safeguards put in place to protect patients in the future.
What you’ll learn:
- What Is a Healthcare Whistleblower Attorney?
- How Whistleblowers Protect Patient Rights
- The False Claims Act Explained
- Common Types of Healthcare Fraud
- Why Healthcare Fraud Cases Are Exploding
- What to Expect When Filing a Whistleblower Case
- Whistleblower Protections Are Real
- The Bottom Line
What Is a Healthcare Whistleblower Attorney?
A healthcare whistleblower attorney is a lawyer who represents whistleblowers.
Whistleblowers are people with insider knowledge of fraud in the healthcare industry. They work with whistleblower attorneys to file qui tam lawsuits under the False Claims Act.
The False Claims Act is a federal law. It allows private citizens to file lawsuits on behalf of the government when they become aware of fraud against federal programs.
The False Claims Act is the best weapon in the fight against healthcare fraud. Because private citizens have an incentive to come forward.
What’s the incentive?
Working with an experienced healthcare whistleblower attorney gives whistleblowers legal protection. It also gives them the potential to receive a portion of any money recovered in a case.
It’s important to note… Exposing fraud without the right legal help can ruin someone’s career. An attorney with experience handling these types of cases is necessary to protect a whistleblower’s identity and employment.
The attorney’s job is to:
- Investigate the allegations of fraud
- File the lawsuit under seal with the Department of Justice
- Protect the whistleblower from employer retaliation
- Negotiate the whistleblower’s share of any recovery
Whistleblower attorneys have a responsibility to act in the best interest of their clients. This includes handling sensitive information with care and ensuring all filings are completed on time and according to the law.
How Whistleblowers Protect Patient Rights
Healthcare fraud doesn’t just cost the government and taxpayers money. It’s healthcare fraud that directly affects and victimizes patients.
Think about it:
- When a hospital bills for services never provided, a patient may be left with a false diagnosis on their medical records.
- When a pharmaceutical company pays kickbacks to doctors, patients may receive unnecessary drugs and treatments.
- When providers upcode to more expensive procedures, insurance premiums increase for all policyholders.
Whistleblowers stop the cycle by coming forward and shining a light on these bad actors. The National Health Care Anti-Fraud Association estimates that health care fraud costs tens of billions annually. Some government agencies place the loss at up to 10% of total healthcare spending. That could translate to over $300 billion dollars every single year.
By helping expose fraud, whistleblowers ensure that healthcare dollars are used to care for patients instead of lining the pockets of fraudsters.
The False Claims Act Explained
The False Claims Act is the primary tool used in the fight against healthcare fraud.
Signed by President Abraham Lincoln during the Civil War, this law was strengthened in 1986 to give whistleblowers even greater incentives and protections.
Here’s how it works:
- A whistleblower (called a “relator”) files a lawsuit under seal.
- The Department of Justice investigates the allegations.
- If the government joins the lawsuit, the chances of success go up dramatically.
- The best part? Whistleblowers are eligible to receive 15% to 30% of the total money recovered. In major cases, that can be millions of dollars.
Since 1986, the government has collected just over $78 billion in settlements and judgments from False Claims Act cases. A whopping 70% of this amount has come from healthcare fraud cases.
Why Healthcare Fraud Cases Are Exploding
The numbers speak for themselves.
Fiscal Year 2024 saw 979 whistleblower cases filed… The most in a single year. Ever.
The Department of Justice recovered $2.9 billion dollars total. With $1.67 billion specifically from healthcare fraud. Whistleblowers contributed to $2.4 billion of those recoveries. And received over $400 million dollars in awards.
What’s driving the surge in cases?
Several factors are at play:
- Medicare Advantage fraud: Investigators are uncovering widespread fraud involving diagnosis code manipulation
- Anti-Kickback violations: Patient referrals paid by other providers remains rampant
- Pharmaceutical schemes: Drug companies continue pushing products for off-label uses
- Billing fraud: Hospitals billing for services never actually rendered continues to be common
The government has made healthcare fraud enforcement a priority. And whistleblowers remain their most effective tool for uncovering these schemes.
Common Types of Healthcare Fraud
Not all fraud looks the same. Here are the schemes whistleblower attorneys encounter most often…
- Billing for services not rendered: Providers submit claims for treatments that never happened. May also use stolen patient information to create entirely fake claims
- Upcoding: When providers bill for more expensive procedures than what was actually performed. Example: billing a simple office visit as a “comprehensive evaluation.”
- Kickback schemes: Healthcare providers receive payments for referring patients to certain facilities, labs, or pharmaceutical companies. Corrupts medical decision making.
- Unbundling: Providers bill each step of a procedure separately when they should be bundled together. Inflates costs significantly.
- Falsifying medical records: Providers enter false diagnoses to justify unnecessary tests or procedures. Creates permanent harm to patient records.
Each of these schemes harm patients. They drain vital resources away from legitimate healthcare needs.
What to Expect When Filing a Whistleblower Case
Thinking about blowing the whistle? Here’s the process, step by step…
Step 1: Consultation
The process begins with a confidential meeting with a healthcare whistleblower attorney. They will evaluate the evidence and determine if a viable case exists.
Step 2: Investigation
The attorney will gather documentation and build the case before filing the lawsuit.
Step 3: Filing Under Seal
The complaint is filed in federal court but remains sealed. This gives the government time to investigate. Without alerting the defendants to the pending lawsuit.
Step 4: Government Decision
The Department of Justice will decide if they want to intervene in the case. If they join, the chances of success increase dramatically.
Step 5: Resolution
Cases can settle or go to trial. Successful whistleblowers receive their share of any recovery.
The process can take years. But patient attorneys will guide whistleblowers through every step of the process. All while protecting them from retaliation.
Whistleblower Protections Are Real
Worried about losing a job for speaking up?
The False Claims Act contains strong anti-retaliation provisions. Employers who retaliate against whistleblowers by firing, demoting, harassing, or discriminating against them face serious consequences.
Protected whistleblowers can recover:
- Reinstatement to their former position
- Double back pay with interest
- Compensation for litigation costs
- Attorneys’ fees
These protections are strong because Congress understands that it takes courage to expose fraud. Without legal protections, few insiders would risk their careers to do the right thing.
The Bottom Line
Healthcare whistleblower attorneys are an important cog in the process of protecting patient rights and taxpayer dollars.
They help transform ordinary employees into powerful advocates for holding fraudsters accountable.
The numbers show that the system works. Record-breaking numbers of cases filed. Billions of dollars recovered. Hundreds of millions in cash awarded to brave whistleblowers.
If fraud is going on, chances are someone on the inside knows about it. Healthcare whistleblower attorneys are helping those people safely and effectively step forward.
The healthcare system depends on it.
