As an employee, you would never expect that your employer is participating in fraudulent activities.
However, if you work for a company that submits bills to government programs, such as Medicare, Medicaid, or Tri-Care, there is a real possibility you may be placed in this position.
According to government audits, as much as 10 percent of all Medicare charges are fraudulent. This includes billing more than once for the same service, charging for services not performed and billing for one type of procedure when performing a less expensive one.
What to Do if You Suspect Fraud
If you become aware of this information, what do you do?
Ultimately, you have two choices – ignore it or alert the appropriate authorities.
Should you choose to report the wrongdoing, you become a whistleblower. Pursuant to the Civil False Claims Act, you can report this action to government, who then pursues reimbursement, as well as civil penalties.
If the government recovers their losses, whistleblowers are entitled to financial compensation – up to 30 percent of the amount the government recovers.
What Qualifies for a Whistleblower Case
So, are you a whistleblower? Here are some examples of cases I’ve handled that fall under the Civil False Claims Act:
- A clinic bills TennCare for services provided by a doctor when they are actually performed by a nurse and should be billed as a nurse’s rate.
- A doctor bills for a procedure using a specific type of machine when he is actually using a different piece of equipment for which Medicare does not permit as high a reimbursement.
- A medical office bills for a specific type of medication when using a less costly generic.
How to Pursue a Whistleblower Claim
This law provides a very specific process for pursuing a whistleblower claim. There are two ways to proceed:
- Contact the local FBI or Department of Justice Office.
- Contact an experienced whistleblower attorney who can guide you through the process.
Because whistleblower cases must follow a specific process, contacting an attorney is recommend. Not only can an attorney lead you through the procedural hurdles in the process, he can also represent you in interactions with the government.
Placing yourself in the posture of a whistleblower is very challenging and even frightening. Trying to handle it on your own is almost impossible. Understanding the best way to proceed will enable you to get through the process successfully.
This blog post originally appeared as a guest article on the Nashville Business Journal’s BizBlog.