We work with whistleblowers to expose fraud against the government.

Medicare, Medicaid & TRICARE Fraud

False claims in health care cost taxpayers billions.

The Government Accountability Office estimated that in 2010 at least 10 percent of all Medicare payments were fraudulent — meaning that Medicare paid out at least $48 billion due to health care fraud in that year alone. Whistleblower lawsuits brought under the False Claims Act (FCA) have been the main tool the government has used to crack down on health care fraud. Specifically, an action may be brought under the Act for false or fraudulent Medicare, Medicaid, or TRICARE billing.

There are many ways in which companies or individuals can perpetrate fraud in Medicare and Medicaid. Recent cases that have settled include claims that large pharmaceutical companies used kickbacks to induce doctors to write prescriptions for the companies’ drugs. The government has also pursued cases in which pharmaceutical companies have marketed drugs for uses not approved by the FDA — a practice known as off-label marketing. Such claims are considered false because the marketing of drugs for unapproved uses is illegal, and also because in most circumstances, Medicare and Medicaid are not authorized to cover payment for such uses.

  • Billing for services not rendered
    • Nursing home billing for supplies never purchased
    • Physical therapist billing for services not provided
  • Falsely certifying individuals as eligible for Medicare or Medicaid benefits
    • Certifying individuals who are not terminally ill for hospice care
  • Upcoding
    • Manipulating coding to bill at a higher level than appropriate — an ambulance company billing for ALS (higher rate) runs when they are doing BLS (lower rate) runs
  • Unbundling
    • Manipulating billing to increase reimbursement — breaking up tests or procedures that are required to be billed as a bundle
  • Unnecessary tests or procedures
    • Inducing physicians to bill for add-on tests not normally included
  • False representations on cost reports
  • Billing for services improperly procured
    • Stark Act violations (improper physician referrals)
  • Best price violations
    • Pharmacy or pharmaceutical company not providing Medicare with best price on drugs

In addition to the federal False Claims Act, many states have their own false claims acts, allowing the states to also pursue local health care fraud claims, including claims involving Medicaid fraud.

What is Qui Tam?

Under the Federal False Claims Act (FCA), whistleblowers have the power to save taxpayers billions of dollars each year by taking a stand against fraud. The U.S. False Claims Act allows private citizens to file suits on the government’s behalf when the government has been defrauded through any federally funded contract or program. The qui tam provisions of the False Claims Act allow these citizens to recover damages. A number of states and the city of Chicago also have laws similar to the False Claims Act to protect against fraud. To learn more about the different types of fraud … READ MORE

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