Healthcare Fraud Whistleblower Lawyer

Insiders are the main way healthcare fraud gets uncovered. If you know about billing fraud, kickbacks or unnecessary care at a hospital, medical group, lab, pharmacy, hospice or Medicare Advantage plan, the law protects you, and in many cases rewards you, for reporting it.

On this page: Fraud schemes · Laws · Rewards · Retaliation · How it works · Before you report · Fees · FAQ

Smith Trial Group represents doctors, nurses, billing and coding staff, compliance officers, sales representatives and administrators who have inside knowledge of healthcare fraud, or who were punished for reporting it. Attorney Cardon Smith spent years defending Fortune 500 companies in complex litigation and served as a law clerk to a federal judge, so he knows how healthcare companies and their lawyers respond when an insider speaks up. Consultations are free and confidential.

Common Healthcare Fraud Schemes

Most healthcare fraud cases involve claims for payment submitted to Medicare, Medi-Cal (Medicaid), TRICARE or other government programs. The schemes we see most often include:

• Upcoding. Billing for a more complex or expensive service than the one actually provided, such as billing a routine visit as a high-level evaluation.
• Billing for services not provided or for medically unnecessary tests, procedures, hospice or home health services.
• Unbundling. Splitting a single procedure into separate billing codes to increase payment.
• Kickbacks. Paying or receiving anything of value for patient referrals, including sham medical director fees, inflated rent, free services, or lavish speaker programs.
• Stark Law violations. Physicians referring Medicare patients for certain designated health services to entities they have a financial relationship with, unless an exception applies.
• Medicare Advantage risk adjustment fraud. Adding diagnosis codes that are unsupported by the medical record so that the government pays the plan more for each patient.
• Lab and pharmacy fraud. Waiving copays to drive volume, billing for tests that were not ordered, or dispensing and billing for medications patients did not need.

The Laws That Apply

Federal False Claims Act

The False Claims Act (31 U.S.C. 3729 and following) is the government’s main tool against healthcare fraud. A person who knowingly submits, or causes someone else to submit, a false claim for payment is liable for three times the government’s damages plus an inflation-adjusted civil penalty for each false claim. Its qui tam provisions let a private whistleblower, called a relator, file the case on the government’s behalf and receive a share of the recovery.

Anti-Kickback Statute and Stark Law

The Anti-Kickback Statute (42 U.S.C. 1320a-7b(b)) makes it a crime to offer or pay anything of value to induce referrals of patients covered by federal healthcare programs. Since 2010, a claim that results from a kickback is treated as a false claim under the False Claims Act. The Stark Law (42 U.S.C. 1395nn) separately prohibits many physician self-referrals. These two laws are behind many of the largest healthcare fraud recoveries.

California False Claims Act

California’s False Claims Act (Government Code 12650 and following) covers fraud on state and local government money, including the state’s share of Medi-Cal. Many healthcare qui tam cases are filed under both the federal and California statutes.

California Insurance Frauds Prevention Act

Fraud against private insurers can also support a whistleblower case. Under Insurance Code 1871.7, a private person can bring a case against providers who pay for patient referrals (often called “runners” or “cappers”) or who submit fraudulent claims to private insurance companies, and can receive a share of the recovery. This law matters because many schemes target commercial insurance, not just Medicare.

Whistleblower Rewards

Under the federal False Claims Act, a relator generally receives 15 to 25 percent of the government’s recovery if the government intervenes in the case, and 25 to 30 percent if the relator proceeds without the government. Healthcare cases often involve years of claims, so recoveries can be substantial. See how whistleblower rewards work.

Protection Against Retaliation

Healthcare workers who report fraud or patient-safety problems have several layers of protection:

• False Claims Act retaliation (31 U.S.C. 3730(h)). Employees, contractors and agents punished for efforts to stop false claims can recover reinstatement, double back pay, special damages and attorney’s fees. The deadline is generally three years.
• Health and Safety Code 1278.5. Protects employees, nurses, doctors and members of the medical staff of California health facilities who complain about patient care or safety. If the facility takes adverse action within 120 days of the complaint, the law presumes retaliation.
• Labor Code 1102.5. California’s general whistleblower law protects employees who report suspected violations of law to a government agency, a supervisor or someone with authority to investigate.

If you have already been fired, demoted or pushed out, see what to do if you were retaliated against for reporting fraud.

How a Healthcare Qui Tam Case Works

1. Confidential evaluation. We review what you know, how you know it, and whether it is “original” information the government does not already have.
2. Disclosure and sealed complaint. We prepare a written disclosure for the government and file the complaint under seal in federal court. The defendant is not served and generally does not learn about the case while it is under seal.
3. Government investigation. The Department of Justice, often with the HHS Office of Inspector General, investigates. You may be interviewed. The seal often lasts well beyond the initial 60 days.
4. Intervention decision and resolution. The government decides whether to intervene. Many cases resolve by settlement.

Timing matters. The False Claims Act’s first-to-file rule generally bars later relators once someone files on the same fraud, and the public disclosure bar can limit cases based on information already made public. See how a qui tam case works.

Protecting Yourself Before You Report

• Talk to a whistleblower lawyer before you confront management or file a report, so that your report is made in a way that preserves your rights.
• Keep a private, dated record of what you saw, who was involved and when.
• Be careful with patient information. Federal privacy rules include a provision for disclosures to an attorney for the purpose of evaluating whistleblower rights, but you should take only what is reasonably necessary and ask us before collecting documents.
• Do not access systems or files you are not authorized to use, and do not use personal email for large document transfers.

Our Role and Fees

We take whistleblower cases on a contingency fee basis, so you pay no attorney’s fees unless there is a recovery. We handle the case from the first confidential meeting through investigation, settlement or trial. Smith Trial Group is based in Newport Beach and represents whistleblowers throughout Southern California. See also federal whistleblower lawyer and pharmaceutical and medical device whistleblowers.

Frequently Asked Questions

Can I report healthcare fraud if I still work there?

Yes. Many relators are current employees. A qui tam complaint is filed under seal, so the employer generally does not learn about it during the government investigation. A lawyer can help you continue working while protecting yourself against retaliation.

Do I need proof, or is suspicion enough?

You do not need to prove the case yourself, but a strong case usually involves specific, firsthand information: who did what, when, and how it caused false claims to be submitted. A lawyer can help you identify what information supports the claim.

How much is a healthcare fraud whistleblower reward?

Under the federal False Claims Act, the relator generally receives 15 to 25 percent of the recovery if the government intervenes, and 25 to 30 percent if it does not. The amount depends on the size of the recovery and the relator’s contribution.

Is there a deadline to file?

Yes. A False Claims Act case generally must be filed within six years of the violation, or within three years after the government knew or should have known the facts, but no more than ten years after the violation. Because only the first relator to file usually qualifies, it is important to act quickly.

What if the fraud involves private insurance, not Medicare?

California’s Insurance Frauds Prevention Act allows whistleblower cases involving fraud against private insurers, including kickbacks for patient referrals. Many schemes involve both government and private payers.

What does it cost to hire a whistleblower lawyer?

We handle whistleblower cases on a contingency fee basis. You pay no attorney’s fees unless there is a recovery.