Whistleblower Attorney in Raleigh, Durham, Cary & Beyond

Qui tam, or “whistleblower,” lawsuits are a type of civil action brought under the Federal Claims Act whereby the whistleblower is rewarded monetarily for funds that are collected against those providers who have committed Medicaid or Medicare fraud, or wrongful billing practices. If an individual has evidence of fraud against any federal or state program and “blows the whistle,” that person is entitled to a portion of the recovery. However, such a whistleblower must take specific steps to ensure their share of the percentage of any recovery.

Medicaid is a state program that provides medical care benefits to low-income individuals. Medicare is the federal program that provides medical care benefits to the elderly and those with severe disabilities. Medicaid or Medicare fraud happens when a provider – which includes hospitals, labs, doctor’s offices, dentist’s offices, nursing homes, pharmacies, clinics, counselors, and home health care providers – knowingly makes or causes to be made a false or misleading statement or representation for the use of obtaining reimbursements through the Medicare or Medicaid programs.

If a provider intentionally misrepresents the services rendered, often they may be subject to criminal and civil penalties. However, if they negligently misrepresent the service rendered, they may be subject to civil recoupment actions by the state or federal government. Some types of Medicare and/or Medicaid fraud include billing for medical services that are not rendered by the provider, billing for medical services that are rendered but are “up-coded” so as to receive a higher reimbursement rate, billing for the same service more than once, or providing services that are not medically necessary and then billing Medicare/Medicaid for them.

Because healthcare costs continue to rise, healthcare professionals are facing increasing governmental scrutiny and regulation regarding unnecessary billing. Sometimes mistakes are made, and therefore audits are often performed by federal and state governmental agencies to determine if a recoupment action could be brought against the healthcare provider. Private insurance companies are also aggressively pursuing the same recoupment actions.