The healthcare industry relies heavily on whistleblowers to bring fraudulent conduct and other forms of waste and abuse to the attention of regulators, law enforcement, and the public in general. If you have found signs of misconduct in the healthcare system, you can perform an important public service by blowing the whistle on it. You can even recover a share of what ends up getting recovered, and can enjoy legal protections from workplace retaliation while you do it.

What Healthcare Fraud, Waste, and Abuse Looks Like

Whistleblowers can report waste, fraud, and abuse to authorities. There are nearly as many ways of abusing or defrauding the healthcare system as there are bad actors who are willing to do it in order to pocket some money.

Just a few of the most common practices are for healthcare providers to:

• Bill an insurance program for services that were not provided or for a recipient who does not exist, also known as “phantom billing”
• Upcoding, which is the practice of providing one service but billing an insurer for a similar, but more expensive, one
• Sending multiple bills for the same service provided
• Unbundling, or billing separately for services that are normally packaged together at a discounted price
• Providing medically unnecessary services in order to bill the health insurer
• Taking financial kickbacks in exchange for referring patients
• Paying patients for them getting medical care

Individual people can also commit healthcare fraud or abuse, though they are relatively rare for whistleblowers to detect. For example, healthcare consumers can:

• Forge prescriptions
• Share health insurance identification cards
• Sell prescription drugs or medical goods or devices that they have received through an insurance program

If you have evidence of any of these courses of conduct, you can become a whistleblower.

A Whistleblower Attorney is a Huge Asset

Odds are extremely high that you have never been a whistleblower before. It is not common for people to gain access to incriminating evidence or other indications of healthcare fraud or abuse. It is far less common for them to gain access to it more than once in their lifetime.

The path forward is going to be unfamiliar.

A whistleblower lawyer who has experience in the healthcare field is someone who has represented numerous people in your situation before. They will have brought forward dozens or potentially even hundreds of cases in the past.

Having a lawyer by your side for this risky endeavor is essential. You get to tap into their experience and benefit from their seasoned advice on how to proceed.

Your Case Can Use Several Different Laws

Depending on the circumstances and the evidence that you have obtained, there are several different laws that may apply to your case. Which one you choose to advance under can make a huge difference in the outcome of your case, the size of the whistleblower award that you recover, and the legal protections that you have in the workplace.

The False Claims Act, 31 U.S.C. §§ 3729 et seq., is the law that is typically the most beneficial for healthcare whistleblowers. The Act imposes civil penalties and treble damages on parties that defraud government programs, and awards whistleblowers a share of the proceeds of the case. Together, this can mean that whistleblowers receive a substantial sum for their public service in reporting the misconduct to the appropriate agency.

However, the False Claims Act only applies to fraud against a government program. In the healthcare field, the big government programs are Medicare, Medicaid, and Tricare. If healthcare fraud is committed against one of these federal insurance programs, then whistleblowers can invoke the False Claims Act. However, if the fraud is perpetrated against a private health insurance company, the Act may not be available and you will have to advance under another federal or state statute, such as the Whistleblower Protection Act (41 U.S.C. § 4712).

Retaliating Against a Whistleblower Violates the Law

Whichever whistleblower law you use, it is virtually guaranteed to have an anti-retaliation provision in it. After all, most whistleblowers only gain access to their information through their employer or while on the job, and it is very foreseeable for that employer to suffer enough from your whistleblowing actions to take action against you.

These anti-retaliation provisions forbid employers from taking action against you for your lawful whistleblowing activities. If you get demoted, fired, suspended, or suffer any other adverse employment action and you can show that it was because you blew the whistle on suspected healthcare fraud, waste, or abuse, you have legal recourse against your employer.

The precise extent of those legal protections from retaliation, as well as the amount of compensation that you can recover from your employer in a wrongful termination lawsuit, will depend on the whistleblower law. However, in order to protect whistleblowers, these laws tend to provide more than a typical wrongful termination claim would.

Healthcare Whistleblower Rewards Can Be Huge

In order to incentivize whistleblowers to come forward, federal and state whistleblower laws generally provide a financial award for information that can be acted upon by law enforcement or investigators. In most cases, it will be a percentage of the proceeds of the case.

This is why the False Claims Act is the preferred vehicle for a healthcare whistleblower case.

“The ‘proceeds of the case’ under the False Claims Act is the amount that was defrauded from the government, plus a civil fine of over $13,000 for each and every claim for compensation that was made. Even if a doctor inflated a charge to Medicare by a few dollars, they would get hit with a $13,000 fine. That amount is then tripled by the treble damages portion of the Act. The resulting amount can be staggering, though most cases settle for a much smaller amount. Whistleblowers are then awarded a percentage of the settlement – up to 30 percent if they prosecuted the claim on their own, or up to 25 percent if the government intervened. But even if your claim does not advance under the False Claims Act, you can still recover a substantial amount for your conduct.” – Dr. Nick Oberheiden, founding partner of the national healthcare whistleblower law firm Oberheiden P.C.