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Medicare Part C Fraud: Everything Whistleblowers Need to Know

Date Published
Jan 09, 2023

Many Americans receive healthcare coverage from Medicare Part C. However, Medicare Part C can be a particularly complex type of insurance through which many scams are perpetrated. Medicare Part C, or Medicare Advantage, involves the opportunity to use public taxpayer funds to compensate private insurance companies who offer services to patients. Because of this exchange of taxpayer money, blowing the whistle on Medicare Part C fraud may allow whistleblowers to collect substantial payouts under state and federal qui tam laws.

If you think you may be in a position to report Medicare fraud, don’t hesitate. Contact a Medicare fraud attorney right away to discuss the specifics of your case. The expert qui tam attorneys at Tycko & Zavareei LLP are ready and available to help explain your options and see determine whether you qualify for legal protections and a financial reward.

What is Medicare Part C?

Medicare Part C involves patients who qualify for traditional Medicare but receive their benefits through a private insurer. Some of the most common structures in Medicare Part C are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).

Medicare Part C is also known as Medicare Advantage. While it may involve working through a private insurance company, many Americans find that they are able to maintain or expand their benefit options through a Medicare Advantage Plan.

What Constitutes Medicare Part C Fraud?

Medicare fraud and abuse are unfortunately common in today’s healthcare system. In Medicare Advantage, privately-held insurance companies receive taxpayer funds to cover the cost of care for qualifying patients. Medicare Part C fraud occurs when the insurance company or healthcare practice purposefully claims a different amount than they are owed in order to turn a profit.

The money that is leeched from the system comes directly from taxpayers. In turn, patients may receive incorrect or ill-considered medical advice in the interest of earning the practice or company more money.

Medicare Part C Fraud Examples

In Medicare Part C, patients are often given a “risk score” that assesses how likely they are to need certain medical care. When insurance companies purposefully inflate a patients’ risk score, they may receive more funding than is actually necessary.

This is just one example of insurance fraud on the back end of Medicare Advantage billing. Other Medicare fraud examples include, but are not limited to:

  • Excessive billing: Billing departments are often the first line of defense when it comes to fighting fraud. One ethical employee can help save taxpayers millions by speaking up when things don’t seem right. Common forms of excessive billing in Medicare Advantage fraud include billing for services that never took place, billing for services rendered by people who are less qualified than the professionals the company claimed performed them, billing for missed appointments, ordering tests and performing services that are not medically necessary, and more.
  • Upcoding and unbundling: Upcoding occurs when a patient’s condition is classified with a higher value code than is actually warranted. Unbundling, on the other hand, occurs when a patient’s medical services which should be billed together are billed separately to increase the monetary value of their visit.
  • Intentional misdiagnosis: Medicare fraud cases involving intentional misdiagnoses are particularly harmful to patients. Intentional misdiagnoses can cause grave physical and psychological harm to patients and their families, while draining taxpayer funds to pay for procedures that can be painful or difficult to undergo. Purposely changing a patient’s risk score may make it more likely that misdiagnoses occur. If you work in a healthcare setting and think you have spotted Medicare fraud red flags involving a misdiagnosis, speak to a qui tam attorney as soon as you can.

Medicare Fraud and Abuse Laws

Medicare fraud whistleblowers are protected by a number of federal and state laws. The government recognizes that supporting Medicare whistleblowers is important for multiple reasons. Both taxpayers and patients are protected when whistleblowers feel empowered to speak up.

  • False Claims Act: The False Claims Act is one of the most powerful anti-fraud laws in the United States. According to the False Claims Act, anyone who knowingly submits false claims to the government may be held liable for up to treble damages, as well as individual financial penalties assessed per claim. Whistleblowers who bring a False Claims Act qui tam claim can receive up to 30 percent of recovered funds in the event of a successful case.
  • Stark Law (Physician Self-Referral Law): The Stark Law is intended to prevent medical professionals from referring Medicare patients to providers with whom they have any kind of financial relationship. This anti-kickback law is meant to protect the sanctity of the doctor-patient relationship and prevent referrals for unnecessary services.
  • Anti-Kickback Statute: The Anti-Kickback Statute has often been applied to Big Pharma in cases involving medical speakers at symposiums or continuing education courses meant to promote the prescription of certain drugs. Besides pharmaceutical actions, it is also meant to prevent kickbacks between insurance companies and providers, or interconnected medical professionals.
  • Exclusion Statute: The Exclusion Statute limits those who have been convicted of certain crimes from receiving Medicare and federal healthcare funding. Crimes that qualify include past Medicare fraud, patient abuse or neglect, or felony convictions involving financial fraud or controlled substances.
  • Civil Monetary Penalties Law (CMPL): Like the False Claims Act, the Civil Monetary Penalties Law may involve a penalty assessment of up to three times the amount wrongfully claimed for a service. Those found guilty of violating the CMPL may be excluded from future payments via the Exclusion Statute.

How Does Medicare Part C Fraud Harm Medical Patients?

Medicare fraud is not a victimless crime. Reporting Medicare fraud is particularly important, as it may protect patients from immediate, actual physical or psychological harm. For instance, providers may knowingly misdiagnose a patient in order to increase their billing capacity to Medicare. This can be traumatizing for patients and their families who are forced to live with a severe misdiagnosis. Patients may believe they are suffering from severe illnesses, and families may wrongfully prepare for a great loss, all because a provider wanted to bring in extra cash.

Other times, patients may undergo invasive or difficult procedures that they never actually needed, just so the insurer or provider can bill Medicare for the process. Common examples of this are unnecessary scans or tests, or even being prescribed unnecessary medication that may cause harmful side effects.

Finally, some healthcare providers bill Medicare at the standard rate while offering patients’ appointments with underqualified employees. Not only do patients miss out on the opportunity to be truly treated for their complaints, but they may also receive faulty or non-professional medical advice that can do real harm.

Who Can Become a Medicare Part C Fraud Whistleblower?

Catching Medicare fraud, waste, and abuse helps improve the system for everyone involved. You can help prevent Medicare fraud and abuse by speaking to a Medicare fraud investigator and/or Medicare fraud attorney as soon as you suspect something is amiss.

Anyone can become a Medicare Part C fraud whistleblower. You do not have to be an industry insider, although most whistleblowers are. Common healthcare whistleblowers include doctors, nurses, billing professionals, insurance company employees, and more. However, some whistleblowers are not directly affiliated with the party committing fraud and instead work for them as a third party contractor. Other times they may even be competitors or outside data analysis experts.

Are Medicare Whistleblowers Entitled to a Reward?

Reporting Medicare fraud is an important step in protecting taxpayer funds and maintaining a higher standard of care for patients by holding accountable unethical providers or those who would otherwise put profit over care. In order to encourage such reporting, and to dispel any professional concerns related to becoming a whistleblower, the False Claims Act rewards Medicare whistleblowers if their claims result in the recovery of stolen funds.

Our qui tam attorneys can help you build the strongest Medicare fraud case possible and pursue the largest award available. In the event of a successful qui tam case, a Medicare whistleblower may be able to receive up to 30 percent of the government’s total recovery amount.

How to Report Medicare Part C Fraud

To report Medicare fraud, contact the law firm of Tycko & Zavareei LLP and share your suspicions. Our team can help you understand what types of proof is necessary to maximize the chances of success in your case. A consultation with our team of expert qui tam attorneys is complimentary and confidential.

Medicare Part C Fraud: FAQs

1. Can Medicare whistleblowers remain anonymous?

While you may suspect that your information is valuable, you may be wondering whether you can report Medicare fraud anonymously. By working with a qualified qui tam law firm, you can better maintain your anonymity throughout as much of the reporting process and investigation as possible. When you work with one of our lawyers, they become your main contact with the Department of Justice, and the complaint is filed under their name, thus protecting yours during the investigation of your claim. If and when your case goes to court, however, your identity may need to be disclosed.

2. Who are the most common perpetrators of Medicare Part C fraud?

Private insurers are some of the most common perpetrators of Medicare Advantage fraud. While doctors and other medical professionals do commit fraud, it is often insurance companies trying to upcode their patients’ risk scores upon submitting for reimbursement.

3. Are Medicare fraud whistleblowers protected from retaliation?

Under the False Claims Act, employers cannot take adverse employment action against employees who blow the whistle on fraud taking place within their organization. Whistleblowers who have been retaliated against can pursue legal action against their employers. Specifically, they may be able to receive up to double back pay, reinstatement, and attorneys’ fees in a successful retaliation claim.

4. What is considered Medicare abuse?

Medicare abuse can be either an abuse of patients who are covered by Medicare, or an abuse of the financial system for financial reward.

5. What is considered Medicare waste?

Medicare waste includes upcoding or overbilling. It typically involves billing for services not rendered, or billing more than what the service typically costs to receive a higher payout per patient.

6. Do Medicare whistleblowers get paid?

Medicare whistleblowers may receive a financial reward for their bravery in coming forward with valuable information. Awards vary, but typically fall in the 10-30 percent range for a successful case.

7. What should I do if I can’t afford a whistleblower lawyer?

The whistleblower lawyers of Tycko & Zavareei LLP work on a contingency fee basis. This means there is no up front fee, and our legal team is paid with a percentage of the overall recovery, just like the whistleblower themselves.

8. How long do Medicare fraud lawsuits typically take?

Medicare fraud qui tam lawsuits may take a considerable amount of time to reach a conclusion. At times, cases may take around two years before final payouts are decided. For this reason, it is especially advisable to work with a professional legal team that can pursue your claim as efficiently as possible.

9. What should I do if I experience whistleblower retaliation?

If you have experienced retaliation such as firing, harassment, threats or intimidation, reduction of pay, or more after becoming a whistleblower, contact the law firm of Tycko & Zavareei LLP immediately to go over your options. You may be able to be reinstated and receive any wages you missed, as well as reimbursement of your legal fees.

10. Is there a statute of limitations on Medicare fraud?

For civil claims, federal law allows for six years before the statute of limitations on Medicare fraud elapses. However, since evidence may be lost or destroyed over time, it is best to bring your information to lawyer sooner rather than later.

Have You Become Aware of Fraud? Talk to an Experienced Medicare Whistleblower Lawyer

Medicare Part C scams are unfortunately pervasive, and it takes the actions of brave whistleblowers to uncover and bring them to justice. If you think you may be eligible to become a whistleblower, speak to our qui tam law firm today to understand the rewards, protections and legal options available to you.

How can we help you?

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Our experienced qui tam attorneys are available for a confidential, no-cost, no-commitment, initial evaluation of your case. Call us now at (202) 973-0900, or begin the process by completing our Confidential Case Evaluation Form.
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